Imagine that you been in labor for 18 hours, and the resident who will be delivering your baby tells you that he hasn’t had any sleep for 25 hours. Would you ask for a new doctor? On the one hand, this resident has been checking you since the beginning of labor. You like him. But, he confides, that this is his second 28 hour shift in three days. He adds that he hasn’t had 24 hours off for two weeks.
An Institute of Medicine (IOM) investigation released in December 2008 concluded that physician fatigue accounts for a growing number of medical errors: “the scientific evidence base establishes that human performance begins to deteriorate after 16 hours of wakefulness” wrote the authors of the report. They called for elimination of resident shifts exceeding 16 hours without sleep. The Accreditation Council for Graduate Medical Education (ACGME), the organization charged with setting and enforcing standards for graduate medical education, has finally responded. New rules regulating how long residents and interns can be asked to work while caring for patients went into effect last month.
In the past, the ACGME let residents work 30 hours at a stretch. But as of July 1, interns (a.k.a first year residents) will be limited to 16-hour tours of duty, following IOM’s recommendation. But, to the dismay of patient safety advocates, under the new rules second and third-year residents still will be permitted to work 28 hours at a time. Moreover, “time off” in between long shifts has been cut from ten hours to eight. This gives residents eight hours to go home, sleep, shower, grab something to eat, and get back the hospital for another 28 hour shift. At best, they may catch seven hours of sleep.
Many doctors believe that long shifts prepare students for the real world of medicine. In a recent post titled “Why work hour restrictions won’t improve patient safety,” Kevin Pho (a.k.a. Kevin M.D.), an internal medicine physician who has become one of the best health care bloggers out there seems to agree: “I’ve often said that there are no work hour restrictions in the real world, so residents used to shift work may find themselves in for a bit of a surprise when they graduate.”
I would argue that lack of work hour restrictions in the real world is part of the problem. Patient safety advocates note that when fifty-something surgeons perform elective surgery after being up all night, patients may be at risk. A meta-analysis cited by the IOM, and conducted by (ACGME)’s own Senior Vice President of Field Activities, Dr. Ingrid Philibert, concludes that after 24–30 hours of sleep deprivation, individual cognitive performance of the average person drops from the 50th to the 15th percentile of their performance when rested, and that clinical performance of physicians drops from the 50th to the 7th percentile of their performance when rested. Typically, patients have no idea that their surgeon has had so little sleep.
Over the past four decades, scientific evidence linking fatigue with accidents and errors in industries ranging from aeronautics to medicine, nuclear power and transportation has spawned regulations to help ensure public safety “with the notable exception of medicine” observe the authors of a white paper on resident hours published in June in the peer-reviewed journal, Nature and Science of Sleep.
The IOM report, and ACGME’s response has re-opened a long-standing debate: How are doctors different from airline pilots? Can they, in fact, learn to function with less sleep? Many physicians argue that learning to remain alert for 28 hours is one of the demands of a profession that expects physicians to be responsible and accountable for their patients. Training residents to work long shifts teaches them endurance, they argue, as well as how to recognize when fatigue begins to degrade their cognitive and physical capabilities. As one physician told Medscape Medical News, "If I've been on call, and done a case, and I have a ruptured aneurysm to do in the morning, I lie down in my office for 15 minutes and come back fresh.”
On the other side of the argument ACGME’s critics point out that other developed nations, such as members of the European Union, have instituted shifts that max out at 13 hours, with 11 hours off afterward. If they can do it, why can’t we? We have a stack of research which reveals that if residents work more than 16 hours, the odds that they will hurt a patient—or themselves—spiral. Nationwide, interns show a 168% increased risk of a motor vehicle crash driving home from shifts lasting more than 24 hours. At the very least, hospitals should provide transportation. Though this raises a question—if the resident is too impaired to drive a car, why would the hospital let him treat a patient 30 minutes before getting into that car?
Dr. Thomas Nasca, CEO of ACGME defends his group’s decision, explaining that maintaining long shifts is crucial for training residents to practice medicine. While limiting shifts for the youngest residents was important to ease them into the profession, he told NPR in an interview at the beginning of the month, older residents must be taught to "recognize and manage fatigue" they will encounter regularly in their actual clinical practice, where hours are not regulated.
Dr. Chris Landrigan a pediatric hospitalist at Children’s Hospital, Boston who has been studying health care quality and sleep deprivation for a dozen years, rejects the argument. “There is a substantial body of medical literature regarding senior residents which shows that if their shifts are limited to 16 hours patient safety and quality of care improves,” says Landrigan, who is an associate professor at Harvard’s medical school.
For example, in one national study more than 2,700 residents in their first postgraduate year were asked to, report on a monthly basis: 1) how much they were working; 2) how much sleep they were getting; and 3) what medical errors they might have made. When researchers compared the months in which a residents didn’t work any extended shifts to months when the same resident worked five or more overnight shifts, the analysts found that when residents worked more extended shifts they were about 7 times as likely to make a fatigue-related mistake that injured a patient. And 1 in 20 reported a fatigue-related mistake that led to a patient’s death.
“I was very disappointed to see ACGME discount the research,” Landrigan told me in a phone interview not long ago. “They say, ‘We don’t have strong data on 2nd and 3rd year residents.’ But we do have eight or nine years of research. ACGME cherry-picks the studies it wants to talk about.”
Perhaps most importantly, Landrigan argues, the notion that 1st year residents should be limited to 16 hours, but 2nd year residents can stay on their feet for 28 hours without impairment “doesn’t make sense physiologically. It seems to me irrational to say that on July 1 of your second year, suddenly, you are able to tolerate sleep deprivation.”
“It’s not like exercise. . . It’s like drinking”
“There is no science showing that if you go without sleep over a period of time, you can learn to tolerate it,” he explains. “It’s not like exercise–with practice you get better. In fact, if you are sleep-deprived over a period of time, say you are getting only four or six hours per night, you become vulnerable to bouts of sleeplessness. When you have 24 hours off, you find that you just can’t sleep.”
As for the belief that residents who work long shifts learn to “recognize” fatigue, Landrigan points out that the science reveals that the longer you are awake, the less aware you are that you are impaired. “It’s like drinking,” he says.
Moreover, instead of slowing down to preserve accuracy as reaction time increases, sleep deprivation often leads people to make hasty decisions based on inadequate information, leading to increased rates of errors.
Those who champion the old rules suggest that if residents work limited “shifts” patients are put at risk during the “hand-off” when one resident goes off-duty and another resident takes responsibility for the patient. The first resident may fail to communicate essential information. But hospitals and medical schools have been focusing on teaching the art of the hand-off. As Kevin Pho acknowledges, “Residency programs have worked hard to close that loophole. At Children’s Hospital in Boston, for instance, errors fell by 40% after the patient handoff process was standardized.” Unlike functioning without sleep, the hand-off is something that can be learned.
Still, ACGME’s Nasca argues that longer shifts are important for patients, whose care often does not fit into 16-hour episodes. For example, a difficult labor and delivery might last much longer. "You may have complications," he says. "Who is better to take care of you during the final phases of the labor than the physician who's been caring for you all the way through?"
This brings me back to the question I posed at the beginning of this post. My daughter, Emily, is having her first baby sometime in the next week or two. When I asked her what she would do if the doctor delivering her baby told her he hadn’t had any sleep for 25 hours, she replied: “I’d ask for a nurse-midwife.”
In part 2 of this post, I will explore why so many hospitals are clinging to long shifts—and discuss the fact that, at some hospitals, residents work even longer shifts than the ACGME allows. At a conference last summer, one resident explained how, at his hospital, residents regularly fill out fake time sheets. While ACGME monitors hospital compliance it does not make unannounced visits. In too many cases, residents work long hours without adequate supervision.
In its report, IOM suggests that ACGME itself needs tighter external supervision—perhaps by the Centers for Medicare and Medicaid or the Joint Commission.
Finally, in Part 2, I’ll explain what Kevin M.D. means when he says that shorter shifts “plug only one hole in a slice of [Swiss] cheese”—and why I agree.”