Dr. Bertrand Bell: Champion of Graduate Medical Education Revisits The Bell Commission
By Jacob Appel, M.D., J.D.
Most medical educators are interested in what their students know. Dr. Bertrand M. Bell, a leading professor at the Albert Einstein College of Medicine, is just as interested in what they don’t know. “What is the greatest challenge facing medical students and house officers?” he asks. “Knowing that you have to ask when you don’t know the answer.” He adds that “medical culture still says the opposite—and that’s dangerous. Arrogance [among physicians-in-training] is still a major problem. If you don’t admit what you don’t know, that’s how you get into trouble.”
Dr. Bell knows a lot about what junior physicians do and do not know. Studying and improving the training of medical interns and residents—he calls them “graduate medical students”—has been a central focus of a medical career that has spanned more than half a century. He is most famous for giving his eponym to the 1987 final report of New York State’s Ad Hoc Advisory Committee on Emergency Services, which he chaired. “Using the formal name of the committee was too long so the press decided to call it the Bell Commission. There were some very prominent people on the committee,” reflects Bell. These included Thomas Morris, the President of Columbia-Presbyterian Hospital, and Robert Friedlander, the Dean of Albany Medical College. “But I was the chairman, so it’s named after me.” The committee was authorized by Governor Mario Cuomo following the publicity surrounding the controversial death of eighteen-year-old Libby Zion at The New York Hospital in 1984. Among its best-known recommendations was an eighty-hour work week for medical residents.
Bell is clearly pleased that, over time, the Bell Commission’s hour recommendations have gained traction nationally. However, he remains concerned that many of the Commission’s recommendations regarding supervision have gone unheeded. “Our findings…emphasized the issue of supervision,” he wrote in a follow-up article, “but it is the hour issue that has always been the focus of the profession and the public.” Twenty-three years after his initial report, he still views better supervision as crucial to improving medical care. “Graduate medical students need to be walked through the process [of delivering care] step-by-step,” he notes. He derides the dictum of “see one, do one, teach one,” which has been a guiding philosophy in American medical education for many decades. “I like to say ‘see one, do one, teach one, kill one,’” he observes, emphasizing that doing a procedure one time is clearly not enough experience to perform it unsupervised in the future.
Needless to say, many in the medical profession resisted Bell’s efforts, particularly those relating to duty hours restrictions, on the grounds that transferring patients between residents more frequently would lead to increased medical errors. Dr. Bell has one word for those critics: “Palaver.” He adds that there is no empirical evidence to support their claims, but much to support his own. “All they have is the Fiddler on the Roof argument. Do you know what that is? Tradition! It dates all the way back to the first residency program at Johns Hopkins.” Bell notes pointedly that the Fiddler on the Roof model kills patients.
Even before his service on the Bell Commission, Dr. Bell was no stranger to controversy. “I was always doing controversial things,” recalls Bell. “I write letters to people. Lots of letters. You know those window guards in hospitals and housing projects? That’s me. I got the ire of Ed Koch when I insisted they would save lives, but he agreed to make it happen—if I stopped writing him letters. I think we saved a lot of lives that way.” Bell is also regarded by many as the father of emergency medicine, as he was one of the first practitioners to approach emergency care as a separate discipline from general internal medicine. Bell faced reprisals after his Commission’s recommendations and was ultimately replaced as Director of Ambulatory Care Services as Einstein, likely as a result of his efforts. Yet he has no regrets. “I’ve never believed in tenure,” he observes with relish, “but I have tenure….I still had a wonderful job that nobody could take away from me. They pay me every day to do a mitzvah.”
At age eighty-one, Bell still enjoys his calling. “Many of my patients have died, but I still go into work four days a week,” he says. “And I still try to find out what I don’t know. I discuss ‘the case of the week’ with my daughter [who practices medicine in Minnesota]. I love going to work. I work with a wonderful bunch of people and everyone knows my name.” Indeed, it may be the only medical eponym many physicians-in-training ever remember.#
