Title Slate: The Eleventh Hour #213, Interns, Rec: 6/14/89, Dir: Andrew Wilk
Funding for program by announcer overlay The Eleventh Hour graphic.
The Eleventh Hour graphic and show opener.
Host Robert Lipsyte welcomes viewers and introduces himself.
Host Lipsyte talks about tonight's program - the overworked (36 hours at a stretch) and tired young interns at hospitals taking care of more and more sick people. After a tragic incident that occurred,he talks about a new law coming up that will change the work practices of all interns and residents. He cuts away to the events that unfolded leading up the these changes.
Pan up on exterior New York Hospital Cornell Medical Center.
Still photo of young red headed girl and the subject of story, Libby Zion as Host Lipsyte unseen narrates about what happened to her.
Photo snapshot of Libby and newspaper article overlay New York Hospital Cornell Medical Center. Lipsyte narrates that Libby after being admitted to the emergency room for an ear ache died the next morning.
Robert Lipsyte's words overlay the photo of Libby and the newspaper article: "overworked...exhausted...too green" - Libby's father charged the doctors had no experience to realize how serious his daughter's symptoms were.
Newspaper headlines overlay photo of doctors looking at X-rays. "Hospital Shakeup Promises to Aid City Interns"; New York Moves to Cut Sharply Interns' Long and Grueling Hours"
Newspaper article from 1987 with picture of Libby Zion, "Grand Jury Ties Hospital Laxness to Teen's Death"
Lipsyte narrates that the Grand Jury failed to indict any of the doctors on the case but put forth recommendations. Bullet points overlay newspaper article with the recommendations: More Supervision (by experienced doctors), Reduced Hours (for residents).
Host Lipsyte in studio, states that the recommendations were challenged by the New York Hospital Association. He introduces his first guest, Libby Zion's father, Sidney Zion.
to the proposed law?
Sidney Zion 4:54
It's a disgrace. They should welcome it. This is there for the help of the patients and for the interns and the residents in the medical profession in general, instead, acting out of the arrogance that fuels them, because they don't want anyone else to interfere with their sovereignty. They decide doctor knows best, you don't decide. There's no way to justify these hours, which often run even more 120. it's not the patient, they care, but the patient is out of the equation. This system is abysmal and has been antiquated from the day I began. Do you think it's only there for doctors?
Robert Lipsyte 5:28
Is their reaction to this, out of this arrogance and traditionalist are economics involved as well
Sidney Zion 5:34
they have been paid the $270 million needed? And I don't even know if it's all that needed? I understand Bellevue did it all with a rejiggering of scheduling the biggest hospital of all and added maybe five interns. It's not an economic thing. And it never was. And it's not a question of getting the enough people they can always do that. The thing they have to understand is, no one ever can suggest that this doesn't hurt patients. They can have any kind of cockamamie time schedule system that they want. But they can't give us a child. That is 36 hour workday can operate well. I wouldn't you wouldn't let a guy drive a cab, you wouldn't let him make your malted milk after 36 hours up, and they're going to let them make life and death decisions. If they claim that they have a problem with not enough staff yet, let the doctors who now have privileges in the hospital spend one night a week or one night every two weeks and do it rather than say that there's no alternative to a slave labor system, which is the economics where they say where they pay them, you know, based on a 40 hour week, they can work 120.
Robert Lipsyte 6:35
So let me stop you. What I hear you saying is let these more experienced doctors our age, let them come down,
Sidney Zion 6:43
let them do it. They do it in smaller towns, they've done it before. And and that's why they say they have to go through this rigorous training. So they'll toughen themselves for later. So later, when they get out. They never show up anymore. Then they say you do it, we did it. You do it. Hey, that's parasolid mentality, you said basic training, that mentality has no business when we are the ones that are going to get impacted. We get hurt. That's why my kid dies. Because they say that they want it their way.
Robert Lipsyte 7:10
What are you going to do if the judge throws out this law?
Sidney Zion 7:13
Well, I can't do anything, unfortunately. But I think the state will appeal it immediately. And I'm hoping that the upper courts won't allow this because I don't see anything. I mean, I'm a lawyer, I've looked it over. I don't see why it's like it'd be any constitutional basis to overthrow it. Most many of the hospitals are all set to go on July 1, the city hospitals, the most stretched, they say we can't afford it. We have too many AIDS patients, you know that this house put on health Corporation of New York City came to a city council meeting only two weeks ago and came out 100% for it, they're happy, they say good, we've got more money, we'll add more people. That's wonderful. That's the attitude to take. They're the ones that are really stretched, not these hospitals upstate New York, hiding behind this hospital association in New York, which is a you know, the whole thing is a joke, because the big hospitals down here, I understand, didn't vote on it. But they want the credit. They want they want to knock it out, they're a little embarrassed to say that they're opposed to this. But they've hid behind this Hospital Association, which comes in and acts as if they're saving patients by throwing out this law
Robert Lipsyte 8:16
Sidney This is kind of the feeling to is that if this hadn't happened to your daughter to Sidney Zion, who's kind of plugged into New York, we wouldn't even be here talking about this, nothing would have happened.
Sidney Zion 8:28
That's the worst part of it all to me. I mean, they said, We killed the wrong kid. That's what they really said. That's a terrible thing to say, there. But that's the reason some of them I understand are mad at some of the doctors involved the way you knew he was a big shot. So why didn't you take better care of this? And that's an answer that makes me throw up to tell you the truth. It is probably true. And it aggravates them more, that if it wasn't for my so called connections, nothing like this would have happened if that. So I'm awfully glad I got the connections because we want to something to come out of this. And but I think that's right, and that's awful that they never would have done it themselves at all and having had it done and by great doctors, by the way, that bell commission probably had the most prestigious and best doctors in the state on that commission. Cuomo deserves a lot of credit for that. And Dr. Axelrod, they were great doctors, they against that. You have a bunch of PR men and small time doctors who were yelling against it without wanting to put their faces out there really say why this isn't a great thing and it's going to save lives. That's what they should be worried about
Robert Lipsyte 9:25
Sidney Zion, thank you very much for being with us.
Host Lipsyte thanks Sidney Zion and introduces next segment of the program. He cuts away to a pre-taped segment with an intern and medical student.
Doctor on telephone as intern looking on. Dr. says goodbye, hangs up phone and intern follows him out of office.
Medical doctor and intern looking at computer screen
Two doctors walking down hallway of hospital
Doctors getting out of elevator and walking down hospital hallway.
Same drs looking at x-rays
Dr. sitting at desk writing notes. He narrates about how hard it is to stop and slow down while covering about 50 patients.
two Drs. checking on female patient laying in bed. They ask how her breathing is making her sit up as they both examine her with stethoscope listening to her breathing.
Camera following drs as they walk down hallway of hospital.
Two Drs. walking into patient's room. Patient in bed is older white male, dr. leaning over asking how patient is doing..
Close up Dr's identification badge clipped onto his white jacket reads, Mark B. Pochapin, MD, Medicine. Host Robert Lipsyte narrating states, "most of New York's hospitals 1,000 beds are occupied, 430 interns and residents work here"...
Two doctors examining older white male patient in bed, patient takes deep breath with mouth wide open. Dr. Pochain is narrating about how an intern making decisions about care, but not life and death decisions.
Dr. Mark Pochapin talking on telephone about a patient.
Dr. Pochapin sitting talking with two other doctors in office. Robert Lipsyte is heard narrating about how in New York hospitals, interns report to residents (drs. who are two-three years out of medical school), and residents report to chief residents who are always in the hospital and to attending physicians who are supposed to be able to get to the hospital quickly.
Close up profile of doctor looking at x-rays.
Dr. filmed from behind, quickly walking up staircase. He is heard talking frustratingly about being very overworked and not having time to spend with patients and this makes it seem like you don't care.
Three doctors in room with patient. One doctor examining patient (obscured) with stethoscope, other doctors leaning in.
Female patient lying in bed appearing to be in pain
Two doctors walking out of elevator and walking down hallway. Dr. narrating about very long hours, 24 hour shift.
Overhead directional sign in hospital hallway, Visitor Elevators, Cafeteria-Exit, N-M Bldgs. Drs are seen entering room
Dr. Pochapin sitting in front of computer, small bed besides him, explains (to unseen interviewer) the "Call Room" where the computer gives the doctors access to patient's clinical history. He talks about maybe getting a lot of sleep tonight without being woken
Close up computer screen - yellow highlights across the screen.
Dr. Pochapin lays down on bed, looks up at camera, pulls on light swicth chain, scene ends.
Cut away to Host Robert Lipsyte in the Eleventh Hour studio. He introduces and welcomes his guests, three medical Residents.: Marilyn Agin, MD; Robert klitzman, MD; and Joseph Sachter, MD.
help me if I go to a hospital?
It's an interesting question. I think what it would do is have doctors available who have had a chance to sleep I think that they will be therefore think less uncomfortable as they perform their work. There'll be less fatigued I think they'll be less angry at times that those odd moments but I think that residents and interns find it frustrating being up all night.
Does that anger and irritation affect the way that you that that residents treat their patients or make diagnoses or make decisions?
One would hope not I think doctors and interns like anyone else are human beings. And in speaking to doctors, particularly after my book came out a number of interns and residents spoke to me about their experiences. And what I found is people would report to me how they had felt quite depressed during their internship quite anxious. quite angry at times residents who've been several years out of their internship would even say to me, they feel they've never quite gotten over internship this several years afterwards. So I think that
and maybe some of the, the the anger and bitterness that we face in older doctors may still have to do with that period of internship. Marilyn do you think that there's too much responsibility given to interns and residents? Our life in the tape? The the young intern said we don't really make life and death decisions. Is that true?
No, I don't agree. I found when I was an intern that especially at night, when you're on call, there's usually a skeleton staff. I was I was the intern, there was a second year there was a third year. And I remember times where I was all alone taking care of some very, some very sick children. Some of them had cancer, we're on chemotherapeutic drugs, we're on IV drips went into fluid in balance, I had to make decisions. Because often the senior was in the emergency room. The second year was in the delivery room, there was an emergency delivery. And although I could call for help, there were times I had to make certainly spontaneous decisions. And as an intern, you don't even really know all the time when there's an emergency. In terms of you know, electrolyte imbalances, these are things that you learn in the course of the year,
have you ever did you ever make mistakes?
Well, no, not real. I'm sure I've made mistakes, nothing that was, you know, irrevocable. And I do remember though, being up all night, and kind of in pediatrics, it's very important to know your dosages. Because it's not like an adult where their standard doses you have to base it on weight. I remember kind of calculating, rechecking myself dividing it again, to make sure I was giving the right amount
to it and making those mathematical calculations tired and yeah, yeah, Joe, you're involved with the committee. One of the things that Sidney Zion said a couple of minutes ago, was that it's not such a big deal to restructure the work practices of interns and residents. Does that make sense to you?
Absolutely. I think it's been our experience that when different departments try to show some flexibility and innovation, you can substantially comply with many of these regulations, recommendations and regulations. Now, simply by rearranging the schedule of doctors, the doctors work. One example I can give you as a metropolitan hospital where the Department of Medicine has taken positive and excellent steps and in in regulating hours, I think they mentioned on the piece here, that New York hospital voluntarily moved down to an 80 hour limitation. I think that 80 hours is key, because I think what we've been discussing here and what people tend to seize on is this idea of person up to 32 hours, 36 hours and the effects that has, and that's important, but I think what's left behind is what happens chronically, what happens to a doctor when they are working 110 120 hours a week, for weeks on end, three, four or five years. And it's that chronic fatigue, that really exerts a very insidious but very predictable effect on all patients. It's not just the isolated patient, which some mistake could have been made
What would be an example of that kind of,
it's it's the chronic fatigue, that I'll give you a specific example. It could be when you're, if you've somehow managed to get bed at three, four in the morning, and the four hours that was quoted on by the stock to your hospital, seems optimistic to me, I never had four hours of sleep when I was an intern. So now it's four o'clock in the morning, the beeper goes off, the nurse calls, Mr. Smith, down, the hall can't fall asleep. Okay. Maybe the reason Mr. Smith can fall asleep is because someone else told him that he has an inoperable tumor, I wouldn't be able to fall asleep either. But it's four o'clock in the morning, you haven't gotten any sleep at all. And the response instead of trying to go to Mr. Smith, and see what's going on, is to just let her sleeping pill. And that's that's the effect of the chronic fatigue. It's treating patients like a collection of symptoms and not human beings. I think that's important, I think it's going giving an order over the phone not seeing the patient, which can often have tragic consequences, as we saw earlier. And I think it's in the part responsible for the kinds of things when patients come back and we can complain about doctors being arrogant, insensitive of not taking the time, all those are traced back to the same things. So I think it's really to the credit of the ad hoc committee of Dr. Bell, Dr. Axelrod, that they addressed this not just in terms of limiting 24 hours. In fact, the initial grand jury recommendation was 16 hours but said 24 Yes, but 80 as well. Now, 80 seems like a lot. But I think in terms of the way medicine is practiced today, it's certainly a step in the right direction.
And beyond even that, the idea that so often the least experienced doctors, were also tired, are being asked to make your phrase was spontaneous decisions. Why in this system Aren't you know, as we've just synchronized doctors, our age, coming back one night, a week, one night a month doing this? Does that would that make sense? Would that have helped you when you weren't intern? Would that have helped those children who needed their doses? modulated
Yeah, I think it would have helped to have more backup. I'm not sure if I would have needed to call a senior attending at three in the morning for something like that. But I just think if there was more staff available, it could even be more senior residents. And as you know, as we just saying, I wasn't so chronically tired. I could possibly deal with this better too
Robert, you talked about so many doctors who have never gotten over that kind of psychic trauma. Do you think that besides affecting interns and residents care immediately that it will affect care for the rest of that physicians life in their attitude towards patients? Which other doctors?
Well I think to a degree, it may, I think that the internship year in many ways needs to be seen in part as a rite of passage. And I think it's important to realize this importantly, is the context for the bell Commission's findings, as it become instituted. And specifically, I think the rite of passage involves a personal transformation that medical students undergo during the internship and making them into doctors, that has a lot of effects, both positive and have some downside as well. For instance, I think two important ones. I think that people want physicians who are compassionate, but I think that we also want physicians who are familiar with disease with people who are dying, so that when someone dies, and a family is in an acute emotional crisis, that someone in that crisis will be level headed, will be rational, be calm will know what to do. And we look at physicians to do that. I think that that kind of adjustment, that kind of coming to see oneself differently happens during internship. The downside, though, I think, is that interns developing this sense of becoming familiar with disease and with dying, can become perhaps hardened or numb to and I think that's the danger that needs to be sort of talked about more, I think, I think that interns and residents need to have a context in which to view their experiences. And I think the other thing that internship does, though, in terms of being a personal transformation, is that it empowers doctors we give in society, society gives doctors tremendous power. In this country, doctors determine what kind of foods we should eat, they determine what kind of sex we should have, what kind of exercise we should do. And similar when someone goes into a hospital patient, an intern, we let intern come and put needles in us put tubes in various parts of our bodies, wake us up at all hours. And the kind of confidence that's involved in the kind of empowering that goes on, I think happens during internship. I think that the internship years in many ways, a kind of personal transformation, which ones comes to see oneself differently, on which one goes through a kind of trauma coming out, in some ways a different person
but we have to find some way to keep the humanity within that year, doctors, thank you very much for being with us.
Host Lipsyte announces upcoming guests, a proponent and opponent of the new law and cuts to break.
The Eleventh Hour graphic and overlay the studio, Host Lipsyte sitting with his next guests.
Host Lipsyte introduces Kenneth Raske, President of the Greater New York Hospital Association a challenger to the new law and Bertram Bell, MD Albert Einstein College of Medicine and Chairmand of the committee that made the recommendations for the proposed new law.
Kenneth Raske 23:00
Well, the new regulations, some of which took effect in January, some of which are taking effect in July, are extraordinarily complicated regulations, which are going to heap a high degree of cost on the hospital community. In addition to that, there is a serious set of resource requirements, including labor, nurses, doctors, etc, all of which have to be hired. So what happened was, the hospital community felt that it was in a crunch in a relatively short period of time in order to make these regulations doable. That led to the consternation that we have today in frustration throughout New York basically an economic challenge primarily an economic challenge. In fact, most of the lawsuit that has been filed by the state association is predicated on economic concerns.
Robert Lipsyte 23:41
Dr Bell, obviously, you've been through this material, you've made the recommendations does that stand up?
Bertrand M. Bell, M.D. 23:47
Well, I'm not an expert on economics. I am an expert in taking care of patients. I do not think that economic issue is an issue of oil. I think that when you consider that 11.5% of the gross national product is in healthcare, I think what we need to do is reorder our priorities. And I think that if the people who are running the voluntary hospitals looked at what they were doing, they could come up with ways in which this very very needed change occurred and everybody put put it together instead of
Robert Lipsyte 24:23
We have heard already that some of the city hospitals have managed to rejigger their schedules and make this work
Bertrand M. Bell, M.D. 24:28
well the city hospitals where I've worked for the last 33 years I'm a pgy 33 actually they don't get very much you know, we we don't put much money into people in need. And so whatever we get we're happy with and as soon as as the state health department and the people who give out money said you guys can have an extra dollar. Well we're very happy that extra dollar and so the people downtown like Dr. Buford and those people looked at it and They said we'll take it and we'll run with it. And that's what we are trying to do.
Robert Lipsyte 25:02
Mr Raske what that sounds like, of course, is that the the for profit hospitals are the ones that are complaining about this, they want to go along with a system that ups their income
Kenneth Raske 25:15
actually not for profit institutions. Let that be clear. And what what the issue is, is simply this that here you have as a backdrop to the current situation, one of the greatest healthcare crisis of modern times occurring in New York, emergency rooms have been backed up over the year, occupancy rates have been extraordinarily high nursing, shortage, nursing settlements of enormous proportions, the beginning of labor negotiations with 1199, and so forth, all of which creates an immense amount of pressure on the institutions. In fact, two out of three voluntary hospitals throughout New York are losing money in 1988. And the 1989 is expected to be the same. Now the question comes, that we're going to spend probably close to $220 million per annum every year for the next forever, presumably, of which when 10 years alone will be over $3 billion.
Robert Lipsyte 26:03
That's the cost and making sure that we don't have tired interns.
Kenneth Raske 26:07
That's the cost of implementing most of the regulations, including the resident, our limitation, all of which is like adding an addition to a house but doesn't take care of the foundation. The foundation of the hospital system in New York is crumbling, and we need to shore it up. At the same time, these regulations well intentioned, there's no question that we've, we've we've never said that they are it's been Ill, Ill conceived in that sense. But we believe that the addition at this point when that foundation is cracking is kind of a misallocation of resources.
Robert Lipsyte 26:36
Do you think that's a misallocation?
Bertrand M. Bell, M.D. 26:38
I can't believe that that people are saying this I that 20 to $20 million is being put in to making patient care better. I think that what Mr. Raskin is saying is that the hospitals want that money. And they want to put it into other things. I have passionately felt that that money needs to be put in to improving the quality of patient care. That's what started this whole thing. That's what Dr. Axlerod wants. That's what we want. And we want to make sure that this money does stay set, there's appropriate supervision, that there's appropriate ancillary help, and that the other thing that no one's talked about, is that when we're talking about, about residents in hospitals, we're talking about graduate medical education. These people are in training, they need to be supervised. The major issue here is supervision. In the public sector, we need money for supervising doctors, when we getting that we're going to hire those doctors. And in the voluntary sector, the supervising doctors are going to have to be around to take care of their patients. And I think that that's where $20 million absolutely must be kept for the sake of patient care quality. And the fact that
Robert Lipsyte 27:45
doctor I'm afraid I'm going to have to stop you there. Thank you very much, gentlemen. This is the 11th hour. I'm Robert Lipsyte.
Interview concludes, Lipsyte announces the show and introduces himself. Show Ends.
Show credits overlay Eleventh Hour graphics.
Funding by announcer and overlay the Eleventh Hour graphic.
Description: The Eleventh Hour - Show #213 Title: Interns Guests: Bertram Bell, Professor of Medicine; Sidney Zion; Ken Rasky, VP Greater NY Hospital Assoc.; Marilyn Agin, MD; Robert Klitzman, MD; Joseph Sachter, MD Original Broadcast Date: 6-14-89 Description: Five years ago (1984)18 year old Libby Zion died in a New York Hospital. Her father, Sidney Zion, blames the tired, overworked, and inexperienced doctors-in-training who treated her. Along with Bertram Bell, professor of Medicine at Albert Einstein College of Medicine, Zion launched a campaign to reform the system. Host Robert Lipsyte discusses the case with Bell and Zion, and Ken Rasky, vice president of the Greater New York Hospital Association, who has filed a lawsuit to prevent proposed implementation of reforms advocated by Zion and Bell. The Eleventh Hour also speaks with several young doctors about how they are dealing with the grueling process of residency.
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