In the 18th century, physicians-in-training literally lived in the hospitals where they worked. Although today’s “residents” are no longer supposed to be sleeping on the job, so to speak, their 30-hour work shifts mean that it’s not uncommon to find them battling shut-eye in the emergency room.
Heroic working hours have long been a badge of honor for senior physicians — the late cardiovascular surgeon Michael DeBakey often bragged that he slept for only five or six hours per night tops. But critics of the policies have long questioned how all these tired doctors affect patient safety and what chronic fatigue is doing to the lives of medical residents at a critical point in their training. For instance, medical residents working shifts longer than 24 hours are about 16% more likely to get into a car accident during their commute back home from work — a problem those live-in docs never had to face.
The debate reached a fever pitch in 2003, and — to avoid proposed legislation from Congress — the Accreditation Council for Graduate Medical Education began restricting residents to 80 hours of work per week, with one full day off and no single shift exceeding 30 hours.
On Sept. 26, the ACGME approved new guidelines that limit first-year interns to 16-hour shifts and encourage direct oversight by attending physicians. The old rules remain in effect for more experienced residents.
Do the new rules go far enough in protecting patients and residents? Read on for two competing views on the topic.
We’ve reached the right balance for minimizing resident hours and maximizing patient safety
Dr. Robert Wachter, chief of hospital medicine at UC San Francisco and blogger at wachtersworld.com
During my own residency in the 1980s, I worked 100 hours per week, and I remember falling asleep while driving home a couple of times. That grueling schedule was not safe for patients or for me. I was pleased when the weekly hours were cut to 80, but the balance sheet is more subtle than people recognize. My own view is that further cuts in hours will lead to more harm than benefit.
Being a physician is not a 40-hour- or 50-hour-a-week job, and residents have to be prepared for the realities of practice. Virtually every doctor will, from time to time, be called in the middle of the night to care for a desperately ill patient. Trainees have to learn how to do this safely.
Residents also learn a tremendous amount from following a patient in the hospital from initial presentation through the next 12 to 24 hours. Over the first few uncertain hours, we make our initial judgments about what might be going on, send off for key tests, consult other experts and tentatively launch a treatment plan. I can’t overstate the value of following the patient long enough for the resident to see how the patient actually did — whether the initial choices were right or wrong.
Reducing the number of residents will also increase the number of times one doctor has to hand off a patient to the next one. Research has demonstrated that medical mistakes increase with the number of hand-offs, and I believe that the detrimental impact of hand-offs is the main reason it is impossible to find hard evidence that patients have become safer since we implemented the 2003 duty-hour limits.
Moreover, I frequently hear from patients these days that “they didn’t know who their doctor was” — the more hand-offs, the less that patients will feel that one doctor really took full responsibility for their overall hospital course.
The transition has already been wickedly expensive. At UCSF, I run the hospitalist program — a new breed of physicians dedicated to taking care of hospitalized patients. Replacing the $45,000-a-year resident with a hospitalist who makes more than $150,000 per year or nurse practitioners who make $100,000 is costing UCSF well over $10 million annually. Nationally, the replacement costs are estimated to be many billions of dollars. This is money we don’t have to invest in preventing medication errors or hospital-acquired infections. There is room for improvement in patient safety in teaching hospitals and for training the next generation of doctors, but it won’t come from additional cuts in duty hours.
Residents need to be working still fewer hours
Dr. Charles Czeisler, sleep medicine specialist at Harvard’s Brigham and Women’s Hospital in Boston
The changes made to ACGME policies in 2003 were minimal, and the new regulations the task force adopted last month are inadequate to ensure patient safety. In 2006, we showed in a study published in the Journal of the American Medical Assn. how little the hours had actually changed due to non-compliance and non-enforcement of the 2003 policies. The new regulations could be even worse, allowing residents in their first year to work several weeks of consecutive 16-hour shifts and residents in their second, third and fourth years to work shifts lasting for 28 consecutive hours twice per week, building up dangerous levels of fatigue.
We are entering an era of evidence-based medicine, where instead of basing decisions on anecdote and intuition, we should be guiding treatment of patients using controlled clinical trials. In 2004, we ran a $2.5-million study to test whether it was better to have a tired physician in intensive care working the traditional hours or to have double the number of hand-offs and physicians working shorter shifts. The most surprising finding in our study is that the ones working traditional 30-hour shifts who stayed with patients all day and night made 5.6 times as many serious diagnostic mistakes as those scheduled to work no more than 16 consecutive hours.
As for costs, in order to implement our 2004 study, we needed to add one resident physician who is paid $50,000 per year by the hospital. To put this in perspective, the 10-bed intensive care unit is billing an average of $50,000 per day, and Medicare is already paying these hospitals $125,000 or more per resident annually. When you consider that a fatigued physician is 36% more likely to make a serious medical error and that adverse events cost the healthcare system $5,000 apiece, it is evident that exhausted physicians not only harm patients but also increase healthcare costs.
Even the Army limits sleep deprivation in boot camp because it realizes that sleep-deprived recruits don’t learn as much. Being able to follow patients is important, but if you don’t sleep on the night after learning something new, you won’t retain the facts. In our study, residents could work for 16 hours one night when patients are first admitted, then get some sleep and return the next morning to work the second half of their shift, which ensures continuity of care.
It’s very difficult to change tradition. Today, people in countries all over the world have gone to jail because they drove a car after being awake for 24 hours and killed someone. Yet we require resident physicians to work 30-hour shifts twice per week. It just doesn’t make sense.