Question: After being on call for 30 hours, the first-year medical resident caused a pneumothorax during a thoracentesis, which was unsupervised because of short staffing. The Accreditation Council for Graduate Medical Education has a rule that limits in-hospital on-call duty to 24 consecutive hours. The residency program itself requires all first-year residents to be physically supervised for procedures such as a thoracentesis. On his way home, the resident momentarily fell asleep at the wheel, struck a car, and injured its driver. Which of the following choices best describes the liability issues involved?
A. Residency program is liable for pneumothorax because it violated its own rules regarding supervision of procedures.
B. Residency program is liable for auto accident because unreasonable work hours were a substantial contributory cause.
C. Resident and program are jointly liable for both injuries.
D. ACGME regulations as well as residency program's own rules are likely to be used as evidentiary standards during litigation.
E. A good plaintiff lawyer will invoke all of the above.
Answer: E. Graduate medical education programs, also called residency programs, are mandated to provide the requisite services and supervision for the education of their trainees. ACGME is the overriding authority responsible for the accreditation of post-MD medical training programs within the United States. GME programs that violate their own rules naturally place themselves at risk for liability. Examples are written rules stating that catheters are to be inserted under the supervision of an attending physician, or that all elective procedures are to be performed with an attending present.
In 1984, 18-year-old Libby Zion presented to a New York hospital with fever and agitation, and died less than 24 hours after admission with an undiagnosed illness. The intern and resident caring for Ms. Zion were questioned about the delay in the patient's being seen, use of restraints, lack of supervision, the contraindicated administration of meperidine in a patient who was taking phenelzine, and failure to make a diagnosis. Although a Manhattan grand jury unanimously dismissed criminal charges, the New York State Board of Regents voted to censure and reprimand the residents for grossly negligent care.
This case alerted the nation to the issue of resident work conditions and led to the creation of the Bell Commission, which found that “inadequate attending supervision, combined with impaired house-staff judgment due to fatigue, were contributory causes of the patient's death.” In 1988, the New York State Health Code implemented recommendations from the commission, limiting weekly work time to 80 hours, and consecutive hospital duty time to 24 hours. These reforms were soon adopted nationwide, with the intent of minimizing fatigue-related errors.
Supervising physicians are commonly named as codefendants for resident error, but program directors and teaching faculty who are uninvolved in direct patient care might also face legal liability, although the chances of plaintiff success are lower. In the example of Swidryk v. St. Michaels Medical Center, Dr. Swidryk was in his third week of obstetrical training when he delivered an infant who developed birth difficulties and brain damage. When he was sued for malpractice, Dr. Swidryk in turn sued the director of medical education, alleging that the director's failure to educate and supervise adequately was the proximate cause of his negligent care. The New Jersey Appellate Court dismissed those claims, reasoning that to decide otherwise would be to interfere with the academic decisions of the university, to encourage a pattern of educational malpractice against schools and residency programs each time a resident is sued, and to unnecessarily increase malpractice litigation if such a tort were recognized.
In another case, a California Appeals court dismissed an action against a professor who was alleged to have offered an opinion regarding treatment. The court ruled that no physician-patient relationship was formed since there was no control over the actions of the actual treating doctor and that to hold otherwise would undermine principles of academic freedom and teaching.
However, in Maxwell v. Cole, the chairman of obstetrics and gynecology was successfully sued for failure to develop and enforce rules regarding qualifications and supervision of trainees. The chairman was not personally involved in the care of a woman who sustained a bladder perforation caused by resident physicians. The court disagreed with the defendant that he owed no duty because no doctor-patient relationship was formed, stating: “If the chief of service fails to provide medically acceptable rules and regulations which would [ensure] appropriate supervision of ill patients, then it is reasonable to find that a breach of the standards of medical care by that individual has occurred.”