Summary: Most hospital patients have no idea that the resident treating them could be coming to the end of a 30-hour shift. If he is exhausted, the resident’s judgment may be impaired. Yesterday, the union that represents some 13,000 residents and interns nationwide (CIRSEIU), the American Medical Student Association (AMSA) Public Citizen, the consumer advocacy organization based in Washington DC, as well as sleep scientists at the Harvard Medical School’s Division of Sleep, announced the results of survey published in BMC Medicine, revealing how little the public knows about residents’ hours.
Sleep deprivation is likely to lead to errors; residents themselves acknowledge that lack of sleep has caused them to make mistakes that harm, and sometimes even kill patients. Exhaustion also affects how they feel about their patients. In 2008, the Institute of Medicine (IOM) recommended capping shifts at 16 hours, saying that longer shifts are unsafe for patients and residents themselves. The Accreditation Council on Graduate Medical Education (ACGME), the group that oversees the training of physicians in the U.S currently allows resident physicians to work for 30 consecutive hours up to twice per week. The ACGME has been reviewing the IOM recommendations and is expected to announce its decision later this month.
The problem: residents represent cheap labor. Some say that the ACGME faces an inherent conflict of interest because its board is dominated by the trade associations for hospitals, doctors and medical schools that benefit from the residents’ long hours. Is this true?
Listen to the voices of residents and interns working in this nation’s hospitals:
“Something I have found remarkable about residency is how much it has eliminated the joy I once had for the practice of medicine. In medical school, I thought delivering a baby was incredible. Now, at 4 am, after 20 hours without rest, I find I that I have lost all sense of compassion towards my patients, just wishing they would ‘deliver the baby already,’ and I always find myself shocked the next morning at how insensitive sleep deprivation made me.
“In my exhaustion, I have forgotten to see patients that I was consulted on in the emergency room, I have confused medication orders, I have fallen asleep while standing up, and I once stuck myself with a contaminated needle on the 24th hour of my shift. I also never expected the physical toll that residency would take on me: the middle of the night nausea and chills, the post-call headaches. I don’t understand why doctors are expected to risk their health and the health of their patients in order to learn medicine.”
-Obstetrics & Gynecology resident, New York, New York
“I drive 30 minutes on a busy expressway to get home after 27-hour shifts when I may have slept anywhere between 20 minutes and 4 hours. I am embarrassed to admit that I’ve fallen asleep at the wheel and by some miracle snapped myself awake before getting into an accident. This has only happened a few times, and it has happened less as I do it more often, but it scares me because it seems totally out of my control. No matter how loud I blast the music or how far I roll the windows down, my body wants what it wants. I am embarrassed because I should know better; as a physician I understand that driving with no sleep is as bad, or worse, than driving drunk. And I am embarrassed because I’ve seen patients devastated by injuries obtained in motor vehicle accidents. I realize it is irresponsible to put myself and other drivers at risk. But time becomes so precious during residency that you’ll take risks for it.”
-Pediatrics resident, Bronx, New York
“I was covering the medicine wards as an intern when a very sick patient arrived from the nursing home around 3 in the morning. I had been up all night running around the hospital attending to the usual concerns on a busy hospital service: admissions every few hours, elevated blood pressures, refill pain medications, follow-up on CT scans done overnight. I was mentally and physically exhausted.
“My team and I wheeled her up to the ICU. Her pulse disintegrated and we began resuscitation. It was then that my emotional exhaustion washed over me. I wished that my new patient would die. At that moment, I cared nothing for my patient, her family, her life. Her living got in the way of my sleep. She was one more name to go on my patient list, one more life to attend to, countless hours I wouldn’t spend in bed.
“Absolute exhaustion elicited by a demanding and disjointed health care system brought out a dark side of me I never want to meet again. That’s the side of a doctor no patient should have to face.”
-Family physician, Los Angeles, California
“What’s it like to work 30 hours without sleep? For me, after about the 15th hour, I become unproductive, although I am still able to perform basic tasks. One area that I find as a surgeon that suffers is the ability to carry out procedural tasks to the same efficiency as when awake and fresh. Post-call, I tend to feel confused in the morning, and very ‘slow’, and I often have to ask people to repeat themselves. I generally have a headache, and my body becomes hypothermic. My eyes ache to close. Yet it is expected that you will work just as well as you did pre-call. In the past, I have made numerous errors in the operating room while post-call. I operated too slowly, and it delayed cases for the attending surgeon. Recently, while post-call, I pulled the wrong chest tube from a patient after
You’ll find these comments in a brochure titled Safe Work Hours/ Safe Patients, produced by the union that represents some 13,000 residents and interns nationwide (CIRSEIU) and the American Medical Student Association (AMSA). The two organizations have joined forces to alert the American public to a major cause of medical errors.
Yesterday, they, along with Public Citizen, the consumer advocacy organization based in Washington DC., as well as sleep scientists at the Harvard Medical School’s Division of Sleep, announced the results of a survey published in BMC Medicine, a peer-reviewed online medical journal, which reveals how little the public knows about residents’ hours.
The Facts about Residents’ Shifts
“More than 100,000 resident physicians in teaching hospitals across the country are routinely scheduled to work shifts of 24-30 consecutive hours, with little or no sleep,” explains wakeupdoctor.org. “They work in operating rooms and ERs, on the wards and in the clinics. And when they are finished working, they get behind the wheel of a car and drive home. After that, they are likely to be back in the hospital for two days of “short” 8 or 12-hour shifts. Then it is another up-to 30-hour ‘on-call’ shift. This brutal schedule can continue for years.”
By contrast, under the European Working Time Directive (EWTD), their counterparts in the UK now work no more than 48 hours per week and shifts are limited to a maximum of 13 consecutive hours.
In the U.S. “one of five resident physicians admits to making a fatigue-related error that has injured a patient, and one in 20 admits to making a fatigue-related error that has resulted in the death of a patient,” observes Dr. Charles Czeisler, who specializes in sleep medicine at Harvard Medical School.
“Working for 24 hours without sleep impairs performance to a degree that is comparable to being legally drunk,” Czeisler adds. “After 24 hours sleep deprivation affects memory consolidation, and judgment,” Czeisler noted in a conference call yesterday morning. Physicians become “fast and sloppy.” At that point, fatigue “degrades performance to the 15th percentile of what rested physicians” are capable of. When it comes to performance, physicians are “used to being in the 95th percentile,” of their performance range, he adds. “That’s how they got into med school.”
Do we have unequivocal evidence that reducing work hours would reduce patient morbidity and mortality? No. As an article in the 2009 issue of the journal Sleep Clinics points out: “An increasing body of literature reveals that physician sleep deprivation puts patients and physicians at risk” suggesting that “rigorous control of work hours probably reduces trainee medical errors. Research that comprehensively elucidates the effects of work hours, sleep hours, and circadian rhythms has the potential to save lives and money by directing data-driven physician work schedules.” But “the effects of these work hour and work schedule limitations on patient and physician outcomes” still need to be “rigorously followed.
Meanwhile, physicians worry about the errors that may result if residents work fewer hours and more patients are “handed off” from one resident to another. Will the second resident receive all of the information he needs? Would the patient be better off with an exhausted resident who has been checking in on him for 20 hours, rather than a fully rested doctor, who has never seen him before? These are problems that can be addressed: medical schools are already beginning to focus on teaching “the hand-off,” while developing checklists and systems to insure that better communication.
In addition, those who call for shorter hours for residents point out, there are many hand-offs in a hospital throughout the day and night: nurses hand off patients, attendings hand off patients. The answer is not to force residents to work inhuman shifts; the answer is to perfect the art of the hand-off.
Morever, no one is suggesting that a resident cannot stay longer, on occasion, to watch over a patient. But the resident who is supposed to pick up his shift should also be there, taking charge of the case, while consulting with the tired physician who knows the patient better.
The Doctor Patient Relationship
Finally, as the testimony from the brochure illustrates, what is certain is that exhaustion has an effect on the physician patient relationship. The National Summit on Medical Errors and Patient Safety Research reports: “Many studies have found that fatigue has deleterious effects on moods and attitude. After one night’s sleep loss, mood disturbance increases, anxiety increases and motivation declines. Hostility and anger also rise with sleep loss and are more prevalent in residents at midyear compared to the beginning of residency training.
“As fatigue and exhaustion mounts, physicians begin developing resentment toward patients. Patients also begin to resent the arrogant attitudes that develop in physicians.” Dr. Timothy McCall writes: “Too few residents emerge from training thankful for the opportunity to practice in a fascinating and intellectually challenging field. Instead, many believe that the world owes them something for what they have been through.”
The ACGME Is Now Considering an IOM Study on Hours
In 2008, The Institute of Medicine (IOM), the non-profit that provides advice on national health issues, recommended further limits including capping continuous shifts at 16 hours. The IOM concluded that longer shifts are unsafe both for patients and for resident physicians themselves.
The Accreditation Council on Graduate Medical Education (ACGME), the group that oversees the training of physicians in the U.S., has yet to implement the IOM recommendations. The ACGME currently allows resident physicians to work for 30 consecutive hours and allows such extended shifts to occur up to twice per week.
In fact, many residents work longer. The Journal of the American Medical Association reports that when residents were promised confidentially 84% admitted violating the 30 hour shifts or the 80 hours a week. (The fact that residents often don’t comply with the rules complicates tracking the effect of shortened hours.)
The JAMA study notes that at many hospitals, senior physicians disapprove of shift limits, ignoring medical evidence about the effects of fatigue. This, I’m afraid, is another example of older physicians letting custom trump evidence-based medicine.
ACGME has been reviewing the IOM recommendations for limiting resident physician work hours for the past 18 months and is expected to announce its decision later this month.
Getting Patients Involved
Hospital patients have no idea that the residents caring for them are working marathon shifts. This is why ( CIR/SIU) and Public Citizen, decided to commission a survey, asking Americans how long they think residents work, and how long they think they should work . The 18 minute telephone survey was conducted by Lake Research Partners, a professional polling company based in Washington and Berkeley, and is discussed here
It turns out that the majority of the 1200 respondents believed that residents work 12.9 hour shifts and 58.3 hour work-weeks. Meanwhile, most felt that these residents should be working shifts that last no longer than 10.5 hours, and that the maximum work week should be 50 hours. When they were told that residents now work 30-hour shifts and 80 hour work-weeks, they were shocked. Eighty-one percent believed that patients should be informed if a treating resident physician has been working for more than 24 hours; 80 percent said they would then want a different doctor.
“The American public realizes that the 19th century practice of scheduling resident physicians to work marathon 24-hour shifts is unsafe for patients,” said Harvard’s Czeisler, who is a senior author of the study. “The 108,000 resident physicians in the U.S. provide much of the direct medical care in our nation’s teaching hospitals, where more than half of all hospitalized patients in the U.S. receive their care. Implementation of a 16-hour work-hour limit for resident physicians, as recommended by the IOM, is long overdue.”
In part 2 of this post, I’ll consider the $64 billion dollar question: can hospitals afford to cut residents’ hours? Residents, after all, represent cheap labor. On the other hand, can we afford to let them continue to work dead on their feet, raising the odds that patients will be injured?
Should someone other than the ACGME be making the decision?
Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much, an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author of the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.