Dr. Bertrand M. Bell, who was instrumental in reducing the grueling shifts worked by interns and residents being trained in American hospitals, died on Tuesday at his home in Manhattan. He was 86.
The cause was kidney failure, his daughter Judith Bell said. At his death he was a professor emeritus at the Albert Einstein College of Medicine.
Dr. Bell’s causes went beyond hospital staffing. He advocated window guards, seatbelts in taxicabs and better training in emergency medicine, advancing his causes through, among other things, prolific letter writing.
But his greatest legacy involved a controversy about overworked and overextended medical trainees, which captured the public’s attention after the death of 18-year-old Libby Zion in 1984 at a Manhattan hospital.
Ms. Zion’s father, the writer Sidney Zion, concluded that the hospital was short-staffed on the night of his daughter’s death and had prescribed her the wrong medication.
David Axelrod, the New York State health commissioner at the time, appointed Dr. Bell to head an advisory panel charged with investigating hospital staffing practices and recommending reforms. He had been an early critic of lax supervision accorded doctors in training and of schedules that left them vulnerable to exhaustion.
The panel’s findings fueled a crusade to limit the training schedule of medical school graduates to 80 hours a week and 24 hours consecutively, and to require more on-site supervision by senior physicians.
At the time, it was not unusual for interns and residents to work 36 hours straight and 95 hours a week. As in the Zion case, they were also forced to juggle large caseloads, evaluate patients without an attending physician on hand and catch naps when they could.
“Often these people are not really doctors, at least in the sense the public understands: experienced, board-certified physicians and surgeons,” Dr. Bell wrote. “They are graduate medical students. Some are interns, often fresh out of medical school. Others are residents who have been at the hospital two to four years. These people should not be taking on total responsibility for the care of patients, and should not be making independent decisions about their care.”
His 1987 recommendations were adopted in 1989 by the state’s Health Department and were later largely embraced by the Accreditation Council for Graduate Medical Education.
But they also generated a backlash among health care administrators that was later blamed for costing Dr. Bell his administrative job at Bronx Municipal Hospital Center.
Some hospitals disregarded the regulations because of staffing imperatives. Others raised medical and academic concerns.
Critics of the new rules contended that an adequately trained doctor should experience firsthand a patient’s often unpredictable initial 36 hours of illness. They also cautioned that trading off patients could impede care by delaying tests or interrupting procedures.
The Zion case began on the evening of Oct. 4, 1984, when Ms. Zion, a college freshman with a history of depression, arrived at New York Hospital (now NewYork-Presbyterian) with symptoms of fever, agitation and jerking motions. She was admitted and evaluated by two young residents.
Her family doctor, consulted by phone, described her condition as a “viral syndrome with hysterical symptoms” and agreed with the prescription of a painkiller around 3 a.m. The younger of the residents, who was caring for 40 other patients, was contacted twice, but Ms. Zion was not re-evaluated. By 6:30 a.m., her temperature hit 107. Shortly afterward, she suffered cardiac arrest and died.
The other resident had been sleeping and was not awakened. The supervising physician had not been called again.
“You don’t need kindergarten,” Mr. Zion wrote in an Op-Ed article in The New York Times, “to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call — forget about life-or-death.”
A grand jury delivered a damning report, criticizing, among other things, the prescribing of the painkiller. Mr. Zion sued and won an award from the two residents, who were declared negligent. The hospital had been fined by the state but was largely absolved by the jury in Ms. Zion’s death.
Dr. Bell later acknowledged that the 80-hour cap on training during the week was arrived at unscientifically. It grew out of a conversation he had with a medical colleague on his porch, he told The Journal of the American Medical Association.
But Dr. Bell argued that those hours, as long they were, were less punishing than the packed workweeks and straight shifts that interns and residents had been assigned before the new regulations were imposed.
“How is it possible,” Dr. Bell asked, “for anyone to be functional working a 95-hour week? A bus driver can’t do it. A pilot cannot do it. So why should a neophyte doctor do it?”
Bertrand Monroe Bell was born on Dec. 19, 1929, in the Bronx. His father, Harry, was a dentist and immigrant from what is now Belarus who changed his name from Bolotsky a few years before Bertrand was born. His mother was the former Edith Yudell, who sang in the Metropolitan Opera chorus.
He graduated from Christopher Columbus High School, where he met Rose Rudel, whom he married. In addition to his daughter Judith, he is survived by his wife; three other daughters, Beth, Lesley and Debra Bell; his brother, Kenneth; and five grandchildren.
Dr. Bell earned a bachelor’s degree from the University of Michigan, attended Howard University for a year and graduated from what is now the University at Buffalo School of Medicine and Biomedical Sciences. (He recalled that his interview for Columbia was terminated after the dean asked him the derivation of his surname; Dr. Bell, who was Jewish, blamed anti-Semitism.)
He served in the Air Force as a pilot, did his residency at Jacobi Hospital in the Bronx and was chief of staff at Calvary Hospital. Returning to Jacobi, he became director of ambulatory care there and also taught at Albert Einstein. He introduced training programs for paramedics, in both primary care and emergency medicine, and for adult and pediatric nurse practitioners. He also began a nurse and doctor home-visit service.
In 1992, Dr. Bell was dismissed as director of ambulatory-care services at what became known as Bronx Municipal Hospital Center over the objections of the city’s Health and Hospitals Corporation.
His supporters attributed his dismissal to friction with the dean of the medical college, which staffed the hospital under an affiliation contract, and to lingering resentment over his aggressive response to the Zion case.