It’s Time To Reform Work Hours For Resident Physicians

In the December 5 Issue:

TABLE OF CONTENTS
Climate might be right for a deal: Copenhagen negotiations will take steps toward a climate-stabilizing treaty
Botanical Whales: Adventures in the Tortugas reveal that seagrass fields need saving too
Breaking the Speed Limit: Studies examine physiology and technology to better foresee the ultimate edge of human performance

It’s time to reform work hours for resident physicians

Harvard sleep researcher says rules should be changed to make sure physicians-in-training get the shut-eye they need

By Charles A. Czeisler

October 24th, 2009; Vol.176 #9 (p. 36)

Text Size

Enlarge

Charles Czeisler"After working more than 24 hours, resident physicians are 168 percent more likely to crash driving home."Division of Sleep Medicine/Harvard Medical School

Last year, the American medical profession admitted that its century-old tradition of sleep-depriving physicians-in-training is unsafe. Working day and night, rather than transferring patient care to a fresh doctor, increases serious medical errors in ICUs by 36 percent, including a 460 percent increase in serious diagnostic mistakes. Twenty-four hours without sleep slows reaction time comparably to alcohol intoxication. Physician-trainees routinely fall asleep during lectures, on patient rounds, while examining patients and even during surgery.

Sleep deprivation impedes memory consolidation and degrades physicians’ clinical performance to the 7th percentile of rested performance. After working more than 24 hours, resident physicians are 73 percent more likely to stab themselves with a needle and 168 percent more likely to crash driving home. One-quarter of them make most sleep-related errors, likely due to sleep disorders or differential vulnerability to sleep loss, which may be genetic. Yet resident physicians with medical conditions that put them and patients at greater risk from sleep deprivation caused by working conditions requiring 30-hour shifts twice per week are seldom provided with a reasonable accommodation.

In 2006, the Harvard Work Hours, Health and Safety Group reported that one in five resident-physicians admitted making a fatigue-related mistake that injured a patient. One in 20 admitted a fatigue-related mistake that resulted in a patient’s death. As a consequence, a U.S. House committee requested the Agency for Healthcare Research and Quality to commission the Institute of Medicine to determine whether long resident work hours compromise patient safety. After studying decades of research and hearing expert testimony, the IOM concluded what many find obvious: the extended duty 30-hour shifts permitted in the current ACGME (Accreditation Council for Graduate Medical Education) limits on resident duty hours “promote conditions for fatigue-related errors that pose risks to both patients and residents.” The IOM recommended that resident physicians should not work more than 16 hours without sleep, should not be awakened from sleep to treat patients and should not drive home after work shifts longer than 16 hours.

This is an important step toward reforming a U.S. tradition established at Johns Hopkins in the 1890s by William Halsted, whose cocaine addiction perhaps clouded his judgment as to how long physicians could safely work. New Zealand has limited physician-trainees to 16-hour shifts since 1985. The European Union limits work shifts to 13 hours, requiring 11 consecutive hours off daily. Unfortunately, just as Wall Street successfully opposed federal regulation of derivative trading, organized medicine has stalled implementation of the IOM recommendations to limit resident work hours.

When other arguments fail, the claim is made that resident work-hour reform is too costly, despite the reality that taxpayers already pay all costs of residency training many times over. Medicare funds teaching hospitals with about $10 billion annually for the 100,000 physicians-in-training in the United States — often paying nearly triple residents’ salaries. Medicare and private insurers then pay those same hospitals again for the medical services residents render. Yet, despite these subsidies, no federal regulations limit the hours these physicians work, exposing them to chronic sleep deprivation that adversely affects their health, increasing their susceptibility to infection and to the risk of hypertension, obesity, diabetes, occupational injury and depression. While on such schedules, 20 percent of pediatric residents screen positive for clinical depression and 74 percent for burnout, a syndrome of mental exhaustion and personal detachment that develops in response to chronic job stress.

Yet 30-hour shifts are deeply entrenched. In 2001, the Association of American Medical Colleges urged hospitals to impose a 12-hour work limit in ICUs, to no avail. The ACGME staved off then-pending legislation by announcing work-hour limits that sanctioned twice-per-week 30-hour shifts rather than eliminating them, refusing to disclose work-hour compliance data from member hospitals, failing to provide whistle-blower protection, abiding falsification of resident work-hour records, and allowing 84 percent non-adherence to current ACGME work-hour limits.

By the residents’ own admission, tens of thousands of patients and residents are injured and thousands of patients lose their lives annually from fatigue-related errors. Many safety-sensitive workers have work-hour limits, including airline pilots and nuclear power engineers. Congress should implement meaningful resident-physician work-hour reform based on the IOM recommendations to prevent these unnecessary tragedies.

Charles A. Czeisler, Ph.D., M.D., F.R.C.P., is the Baldino Professor of Sleep Medicine and director of the Division of Sleep Medicine at Harvard Medical School and chief of sleep medicine at Brigham and Women’s Hospital in Boston. In 1970, he was a finalist in the Westinghouse Science Talent Search, a competition organized by Science News' publisher, now called the Society for Science & the Public. Read more about the science of sleep and sleep health at understandingsleep.org

Found in: Science & Society

Share & Save

Comments 3

If you look at basic learning theory, you see that people learn best when they're well rested and unencumbered by distractions. However, learning theory also shows that reinforcement is best under extremely adverse circumstances. If you stitch up a patient while you're half asleep, you'll be able to do it in the future while half asleep.

So, I agree that resident physician's sleep should be managed better. Ideally, there should be a deliberate attempt to require shorter hours when learning new things, and longer hours when applying what was learned. This, obviously, isn't always possible, but I think any new regulation should allow this type of flexibility to exist.

Gary Godfrey

Oct. 11, 2009 at 12:11am
I'm a physician and the idiocy of the sleep deprivation feature of the training tradition has long been obvious to me. It is just one part of the hazing that medical trainees endure, as students, interns and residents. To me, the question is, why do these traditions endure? What is the psychosocial pathology behind it? What are the properties shared by the medical profession, criminal gangs, college fraternities, and many aboriginal tribes that make them perpetuate such onerous initiation rituals? (A broader question is, why does society rely on "experts" to decide issues about which they should have lost all credibility - this example is doctors running medical training, but others include central bankers managing the monetary system, politicians conducting foreign policy and the education profession operating the schools.)

Michael Lenker

Oct. 15, 2009 at 9:04pm
Czeisler's commentary (Oct 24th) makes a good argument for reform of resident physician work hours. There are, however, at least two important points that he does not discuss.

1. The number of physicians in practice exceeds the size of the resident physician pool by perhaps an order of magnitude, and extended work hours do not end with resident physicians. In order to have blocks of time-off, many practicing physicians voluntarily put themselves "on call" for multiple consecutive days. Yet, if they put patients at risk in doing so, there is no mechanism to regulate their work hours.

2. Shortening work hours necessarily decreases the continuity of care and increases the number of number of "sign-outs" between physicians. The quality of sign-outs is variable. Poor communication between physicians can also increase the risk of patient injury. It is unclear whose risk is greater: the patient with a sleep deprived doctor, or the patient with a doctor poorly informed about the patient's condition.

Don Smith, MD
Denver, Colorado

Don Smith

Oct. 26, 2009 at 11:58am

Suggested Reading:

For more information, see [Go to]
Read more about the science of sleep and sleep health at understandingsleep.org [Go to]

Citations & References:

Barger LK, Ayas NT, Cade BE, Cronin JW, Rosner B, Speizer FE et al. Impact of extended duration shifts on medical errors, adverse events, and attentional failures. PLoS Med 2006; 3(12): 2440-2448.
Institute of Medicine of the National Academies. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Ulmer C, Wolman DM, Johns MME, editors. 1-322. 2008. Washington, D.C., The National Academies Press.
Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351(18):1838-1848.
Institute of Medicine. Sleep disorders and sleep deprivation: An unmet public health problem. Colten HR, Alteveogt BM, editors. ISBN:0-309-66012-2, 1-500. 2006.
Washington, D.C., National Academies Press.
Czeisler CA. The Gordon Wilson Lecture: Work hours, sleep and patient safety in residency training. Trans Am Clin Climatol Assoc 2006; 117:159-189.
Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep 2005; 28(11):1392-1402.
Ayas NT, Barger LK, Cade BE, Hashimoto DM, Rosner B, Cronin JW et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA 2006; 296(9):1055-1062.
Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med 2005; 352:125-134.
Czeisler CA. Medical and Genetic Differences in the Adverse Impact of Sleep Loss on Performance: Ethical Considerations for the Medical Profession. Trans Am Clin Climatol Assoc 2009, in press.
Markel H. The accidental addict. N Engl J Med 2005; 352(10):966-968.
Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ 2008; 336(7642):488-491.
) Landrigan CP, Barger LK, Cade BE, Ayas NT, Czeisler CA. Interns' compliance with accreditation council for graduate medical education work-hour limits. JAMA 2006;
296(9):1063-1070.