From the editor

SECOND OPINION
BY SIDNEY HARRIS

The 80-hour week, and its aftermath

I read with interest your recent article on resident hours [“Re-creating the Residency,” Fall/Winter 2004]. I was among the physicians who testified at the grand jury that investigated the Libby Zion case. While it is true that the grand jury did not indict anyone, they did find that there was a significant cause for concern and issued a report to the New York state legislature. This led to the formation of the Bell Commission, which recommended the 80-hour workweek and increased supervision of house staff. It was this report that ultimately led to the passage of the 80-hour limit for house staff in New York.

The invective from organized medicine against these rules was ferocious. It put medicine at direct odds with the public, for whom these rules were self-evident and made unquestionable common sense. They believed that no one could work 100 to 120 hours a week and still provide the level of care and cognitive functioning that the public required of their physicians. They also intuitively understood that the more physicians were asked to deny their own needs while in training, the less they would be able to cater to the needs of their patients while in practice. The more medicine railed against the rules, the more the public began to question its judgment. As you correctly pointed out, in many ways this was one of the strong impetuses for the patient safety movement. In addition, as medicine chose to specifically break the law in New York by not adhering to the hours limit, the public perceived medicine as viewing itself as being above the law, as being paternalistic and as acting in its own financial best interests. The resulting furor has led, in part, to the distrust that has been increasingly seen in the public’s opinion of American medicine.

Yale has now taken a leading position in the intelligent implementation of these rules. Yale’s leaders assessed the problems for patient care that the rules raised and put into effect specific solutions that addressed them. They committed themselves to an ongoing look at the process and continued improvement as problems arise. The resulting system of training will be good for patient care, house staff training and the view of medicine by the public.

Gerald M. Brody, M.D. ’77
Tuckahoe, N.Y.

Enlightened HMOs make time for CME

Writer Jill Max quoted Lawrence S. Cohen, M.D., as saying: “One of the challenges in the environment is that physicians, because of managed care, find it increasingly difficult to leave the practice and go to a meeting.” [“Yale CME Gets a New Lease on Lifelong Learning,” Fall/Winter 2004.] I find this statement contrary to my experience with the Southern California Permanente Medical Group (SCPMG), a part of Kaiser-Permanente.

I joined SCPMG in July 1967 and became chief of ob/gyn. From the beginning, my department had weekly, mandatory, half-day CME meetings plus a weekly Friday morning hour for quality review. Speakers from the Department of Reproductive Medicine at the University of California, San Diego, were often present. Later, when the UCSD residency began, our hospital was the first in San Diego to have a resident.

Our partnership agreement specifies a half-day weekly of paid education time plus one week paid yearly to attend an educational meeting. I never had these benefits when I was in solo practice in Brockton, Mass. Because of these educational opportunities, as regional clinical coordinator for SCPMG, I was involved in improving the quality of practice. Two of our hospitals, in San Diego and Los Angeles, became No. 1 and No. 2 in the state for quality.

Myron K. Nobile, M.D. ’47, HS ’54
La Jolla, Calif.

Dr. Cohen responds: “My comments did not apply to groups such as yours, but they do apply to the average practitioner who is in a solo or group practice. In that instance, time away at conferences that award CME credits are not easily come by. It is true that grand rounds and specialty conferences are often given at the hospitals, but many physicians are not encouraged to attend; I applaud the success of your program at Kaiser-Permanente.”

Merson steps down as dean of public health

As this issue of Yale Medicine was being prepared, we learned that Michael H. Merson, M.D., the Anna M.R. Lauder Professor of Public Health, would step down as dean of public health and chair of the Department of Epidemiology and Public Health (EPH), as of December 31, 2004. Brian P. Leaderer, M.P.H. ’71, Ph.D. ’75, the Susan Dwight Bliss Professor of Public Health, was named interim dean and chair during a search for a successor to Merson. Nancy H. Ruddle, Ph.D. ’68, the John Rodman Paul Professor of Epidemiology and Public Health, will serve as interim deputy dean and vice chair.

Merson came to Yale in 1995 from the World Health Organization in Geneva, where he directed the Global Programme on AIDS. At Yale he continued his efforts to stem the pandemic, forming the Center for Interdisciplinary Research on aids (CIRA), which undertakes research and prevention programs in the United States, Russia, China, India and South Africa.

He has also raised the profile of the public health school and has fostered joint-degree programs with other professional schools at Yale, including nursing, law, management, forestry and environmental studies, and divinity.

After a sabbatical, Merson will return to the public health faculty later this year. He will also continue as director of CIRA.

Leaderer joined the EPH faculty in 1976 and is the principal investigator of studies that examine environmental and genetic factors of asthma in children. Ruddle directs graduate studies in public health. She studies cell trafficking and inflammation, particularly with regard to the lymphotoxin/tumor necrosis factor family. She has been on the Yale faculty since 1975.

From the Editor:

Fish tales, on the up and up

Last September, I was listening to a lecture in the Anlyan Center when a fascinating bit of data flashed on the screen. Assistant Professor of Genetics Zhaoxia Sun, Ph.D. ’98, was describing her use of zebrafish as a model organism for the study of polycystic kidney disease and alluded to how compact and convenient they are for laboratory work. The 600 small tanks on racks in her lab at the medical school can hold as many as 15,000 zebrafish, a species whose DNA bears a remarkable similarity to our own genetic code. Given the rapidity with which zebrafish develop (from egg to fish in a day), Sun has a powerful resource for conducting genetic studies relevant to human illness.

We wondered what other aquatic organisms were assisting scientists at the School of Medicine as they explore the dimensions of normal biology and disease. Sea hares, with their elongated neurons, and sea squid, with synapses so wide they can be seen without a microscope, are among the creatures writer Jennifer Kaylin encountered while reporting this issue’s cover story (“Lessons From the Depths”). She also learned how knowledge of chloride transport in dogfish sharks may one day help solve the riddle of cystic fibrosis and how a professor of physiology and neurobiology is exploring Australia’s Great Barrier Reef to discover and clone new fluorescent proteins from coral. These molecules may prove useful for tagging cells and exposing what happens inside them—in real time and brilliant color.

Science and medicine are always changing, and it’s gratifying to know that Yale faculty are leading the way in areas such as these, asking the questions that open doors to new knowledge. That curiosity and sense of adventure can only benefit doctors and patients around the world—and across the seven seas—for years to come.

Michael Fitzsousa
michael.fitzsousa@yale.edu