New Limits On Resident Physicians' Hours -- Do They Go Far Enough?

When you think of the rigors of medical training what's the first thing that comes to mind? I'm guessing you conjured the image of a sleep-deprived young resident roaming a late-night hospital corridor, fighting through fatigue in order to see her next patient. The notion of this sleepless rite of passage for doctors-in-training is deeply entrenched in our medical school culture, and has been reinforced by decades of TV medical dramas.

The truth is that sleep deprivation actually inhibits residents' learning, and makes them more likely to make errors that can harm their patients. That's why this news is so important and so welcome: This month, changes went into effect that limit the amount of time first-year residents can spend working without time off. These changes are a partial implementation of recommendations made by the Institute of Medicine (IOM), which conducted a comprehensive study in 2008 on the effects of resident physicians' hours on medical errors.

Previously, residents were able to work as long as 30-hour shifts without time off, and up to a total of 80 hours per week. Residents may still work as much as 80 hours in a week, but first-year residents can work a maximum of one 16-hour shift before they must take off at least eight hours. Second and third year residents are able to work up to 28-hour shifts without time off, but they may not take on new patients after the 24-hour mark. While this sounds crazy, it is actually an improvement!

Depriving our doctors of sleep as part of their training is unhealthy for physicians, and it can be downright dangerous for their patients. Medical errors are an enormous -- and expensive -- problem in our health-care system. Estimates vary greatly, but it's clear that tens of thousands of patients suffer the consequences of medical errors each year. There is strong evidence that residents who work extended shifts are far more likely to make medical errors:

• One study showed that interns made 35.9 percent more serious medical errors while following a traditional extended-shift work schedule than when they worked a shorter schedule with longer breaks between shifts.
• While working extended shifts, first-year residents in another study demonstrated a significant increase in fatigue during lectures, rounds and clinical work, as well as 300 percent more preventable errors that resulted in fatalities.
• Extended work shifts have been shown to pose a safety hazard for residents themselves. One study revealed extended work shifts significantly increased their likelihood of getting in a car accident on the way home from work.

You don't have to be a sleep-deprived medical student to know what happens to your body and your brain when you don't get enough sleep. Sleep deprivation has mental and physical consequences that can significantly impact our ability to function:

• Sleep deprivation causes the brain to actually shut down in certain regions. This causes sluggishness, slows reaction time and clouds judgment.
• Deprived of sleep, we're also hampered in our ability to learn -- and to convert our new learning into long-memories.

As the hours pile up without sleep, residents are less and less able to retain the information they need to learn, and less able to make smart -- and safe -- choices for their patients.

Nowhere is the image of the sleep-sacrificing doctor-in-training more entrenched than inside the medical community. These changes have brought with them debate and resistance from some medical professionals who argue that the shift restrictions do not allow new residents to build the endurance they'll need in their careers, and will also bring burdensome financial costs to hospitals. Others welcome these changes, but suggest they do not go far enough. (The general public is overwhelmingly in favor of limiting the work shift hours of residents in their hospitals.)

Count me among those who believe there's still work to be done here. Limiting first-year residents to 16-hour shifts is a start, but what about extending those restrictions to all residents? This is just one of the recommendations made by the Institute of Medicine. The IOM also recommended:

• Increasing limitations on how often residents can be on-call without time off
• Extending time off between shifts to a minimum of 10 hours, with longer minimum breaks after night shifts or extended shifts
• Limiting the frequency of overnight shifts, and ensuring extended time off after several consecutive night shifts

Clearly there's more to be done. But this month's changes are an important step toward getting hospital physicians the sleep they need, so they can care for us to the best of their ability.

Sweet Dreams,

Michael J. Breus, PhD 
The Sleep Doctor™ 
www.thesleepdoctor.com

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Comments

[tomteboda]

01:05 PM on 08/01/2011

Thank you for this update! As a person in a family with many medical professionals, I'm glad to see that the physicians rules are taking account of something everyone's known for years; that exhausted doctors are exhausted human beings, and exhausted human beings have impaired reactions and judgement, as well as the exhaustion taking a long-term toll on their health. These changes are a positive step towards an overall healthier medical environment for physicians and patients alike.

[MommyMD]

04:46 PM on 07/31/2011

As someone who worked in both the 100+ hour system and the 80 hour system, I will begrudgingly share the news that patients are absolutely safer when the SAME resident follows him or her throughout the course of the patients hospital stay. This means that work restrictions should be kept to a sane minimum. One simply cannot learn medicine, feel entirely responsible for a patient, and take excellent care of a patient when one has to leave abruptly at the end of 16 hours. Medicine is not nursing (also a noble profession) and illness does not obey shifts.
-I have no axe to grind since I benefited from both systems, but leaving abruptly after 16 hours, "signing off" your patient to another resident/intern who has know idea the nuances of your patient's case is like stopping in the middle of a book-thriller going to sleep, waking up, and picking up the book 100 pages later with little explanation as to what happened in between. Medicine (under health insurance) is flawed for certain. But today's young docs are called to their profession. They know the work it will take to make them stellar physicians. As a doc, a prof, and a former long-time pt., I can say it is FAR safer for the patients for their resident to be tired (within reason....80-90 hours) than to constantly pass off patients.

[Megandale]

09:14 PM on 07/31/2011

Wow, MommyMD - what an excellent post. Thank you.

[Phenomenologist]

03:55 AM on 08/02/2011

Dear MommyMD:

While I appreciate the compassion, rationality, and restraint that usually characterizes your comments, I am puzzled by what you are claiming here. Are you advocating an increase in the hour limit of extended duration work shifts so that residents can follow their patients continuously for as long as possible?

If so, do you have any criticisms of the two studies that Dr. Breus cited to demonstrate that extended duration work shifts increases the incidence of serious or fatal medical errors? Have studies shown that abruptly leaving the hospital after reaching the 16-hour or 28-hour limits increases the incidence of medical errors compared to having the patient be followed by the same resident throughout the entirety of his/her hospital stay? Compared to the 100+ hour system?

This is a question that requires a careful evaluation of available evidence.

[MommyMD]

05:50 AM on 08/02/2011

You are a careful and compassionate blogger as well.
-The two studies cited by the psychologist were conducted on interns in 2002 at Harvard hospitals, one limited only to ICU level care. Since I was there at that time, I can speak first hand that the call system studied was indeed abusive and dangerous to patients and residents. (There is no reporting of actual hours, but I personally recall 100-110/week during ICU months.) Certainly this is outrageous. Fatigue, mistakes, and unfortunately deaths occurred under these circumstances. I believe that an intervention was sorely needed in this case.
-The second study was also completed in 2003-2004 (same institution), and is flawed for a # of reasons. For example, it does not address that top tier residents are far more circumspect in their signing out than their average counterparts.
-I DO think that resident hours should be limited, but the new rules are too extreme. A 60 hour work-week with 16 hour shifts will entail frightening sign outs that will place patients in jeopardy. I see this now: my own trainees have no sense of the progression of a case, and often not even the patient's name. The original admitting residents, knowing they are "off" in 16 hours get the ball rolling and "dump" the patient to the next colleague. The poor patient has no idea this is going on. In between, no one learns medicine.
-A compromise of 80 hours/week seems reasonable and safe.

[MommyMD]

05:50 AM on 08/02/2011

Again, since I have benefited from both systems, I have no personal masochistic tendencies to make my own residents suffer the way I did. I would just like all patients to have the continuity of care and well-trained docs they deserve.

[ejlindsay]

02:34 AM on 07/30/2011

It seems completely absurd that doctors, of all people, would force their residents to work such health-crushing hours. How can a doctor really care about the health of their patients when they seem to value their own so little?