Medical

Sleep Deprivation and Residents: Are We on the Right Track?

The tradition of long hours on the floor is an old one in American medical training. And criticism of this tradition is of long standing too. The controversy over the grueling residency schedules is not a new one, but neither is it one that has been successfully resolved. It can still spark off strong feelings in both the proponents and opponents of cutting back on the length of residency shifts and/or the time off between shifts for professionals engaged in this important stage in their medical education. What’s more, it is a topic which has pitted respected healthcare institutions such as the Harvard School for Public Health and the American Academy of Family Physicians against one another, so much so that this issue is not likely to be resolved anytime soon.
This Issue in Context
The change in attitude towards residency hours has not been a dramatic “one-eighty”. It has, instead, been a matter of small shifts in recent decades that, by and large, is in favor of shorter shift hours and more time off between shifts for doctors serving in their residency. However, this change has been slow in coming and there are still many in the medical profession who are critical of these shifts.
The First Change
The first change occurred back in 2003, when the Accreditation Council for Graduate Medical Education (ACGME) capped the number of hours that residents could work at 80 a week. However, they maintained that, even with this cap, it was still acceptable for residents to work 30 hours at a stretch.
The IOM Investigation
In 2007, at the behest of Congress, the Institute of Medicine launched an investigation into whether or not there was a link between this grueling schedule and an increase in medication errors and/or poor patient outcomes caused by physician fatigue. Its finding were published in 2008 and stated that in order to ensure patient safety, there had to be increased supervision and regulation of residency work hours.
The Newest Changes in Residency Rules
The latest formal stage in this ongoing debate came in 2011, when the ACGME once more changed the regulations governing residency work hours. The shift cap for medical residents in their first year is now at 16 hours. Second and third year residents can work up to 28 hours in a shift. Also, in the final four hours of that shift, they are not allowed to take on new patients. However, the time in between shifts was cut from ten hours to eight.
Critics believe that this changes send a mixed signal and also that even these new rules fall short of truly implementing the recommendations set down by the ACGME. Let’s take a look at the debate which continues to be divisive for the medical community and which has lined up both revered institutions and experienced physicians on both sides of the debate.
The Argument for Shorter Shifts
Proponents of changes in residency hours tend to be passionate about their conviction that current practices not only increase the risk for harm to the patient but to the doctor and, ultimately, to the communities in which they serve.
Deterioration of Physician Performance
The strongest argument against the kind of harsh schedule that has traditionally been the lot of many residents is that of the deterioration of physician performance due to mental and physical fatigue. Dr. Chris Landrigan of the Harvard School of Public Health believes that residency shifts should be capped at 12 hours and that longer shifts are both ridiculous and dangerous. “This is not based on science. The evidence is clear that you don’t learn how to handle sleep deprivation. It’s ill-conceived.”
Landrigan believes that OSHA should actually step into this fray because of the danger it poses to residents themselves. And multiple studies have shown that residents who are chronically sleep deprived are at a higher risk for motor vehicle accidents, sharps injuries like needle sticks and mental health issues. In the long term, lack of sleep can also put physicians and others at higher risk for being overweight or obese or developing diabetes or heart disease. All of these possible negative outcomes might possibly make this more of an occupational health issue.
The IOM report in 2008 concurred with this opinion and noted that “the scientific evidence base shows that human performance begins to decline after 16 hours of wakefulness” and did call for an elimination of shifts exceeding 16 hours – which, to date, has not yet be implemented. Their meta-analysis of studies done on this subject, for instance, found that after 24-30 hours without sleep, cognitive powers slipped from the 50th to the 15th percentile. Another study, where 2,700 residents were encouraged to write down their shifts, hours of sleep, workload and what, if any, medication errors they had made, it was found that when residents slept more, they were seven times less likely to make mistakes that led to patient injury.
Many critics also note that in the European Union, residency hours are restricted even further with no negative impact on medical care: residents are not allowed to work for any longer than 12 hours at a stretch. They are also guaranteed to have at least 11 hours off in between these shifts.
The Argument against Shorter Shifts
Those who oppose the changes in residency schedules are equally adamant about their belief that the current system for residents is the best one, citing tradition as well as the need for doctors to learn how to deal with lengthy hours and a physically demanding workload that will follow them for most of their career.
Patient Safety and Long Work Hours: is there a Link?
One of the biggest opponents to these residency hour changes is actually the CEO of the ACGME itself, Dr. Thomas Nasca. While he acknowledges that this schedule is tough, he also believes that the danger to patients is minimal, since at this stage the residents are closely supervised by more experienced doctors. Thus, even if a resident did make a medication error due to fatigue, there would be controls in place to catch this error before it can harm the patient.
One study often cited by physicians who believe that the “old school” style of residency was superior is one which came out in 2009. This research, conducted on V.A. medical campus found that, after the 2003 restrictions were implemented, found that mortality rates among patients did not improve even though the residents were presumably better-rested.
Another study of 6,751 cardiac surgeons found that there was no difference between the success of surgeries performed by doctors who had slept the night before versus those who had been awake all night. Authors believed that this might be because certain procedures are less susceptible to sleep deprivation than others.
Welcome to Real Life
Another important argument often cited by opponents of residency change might be termed the “welcome to real life” argument. It goes in like this: many opponents to these changes base their beliefs on that fact that doctors, when they get into their own practice, are going to find that they routinely keep long and extremely tiring schedules. For instance, Kevin Pho (well-known author of the Kevin MD site) is against these changes. On his blog he notes, “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.”
Other doctors agree, noting that, depending on a physician’s specialty area, there are many medical situations a doctor may find him- or herself in that require more than 16 hours’ worth of work and concentration: for instance, a complicated surgery or a case of prolonged labor. These doctors argue that physicians who have been hardened to long shifts and a high workload during residency can handle these situations better and have more physical/mental stamina built up.
The Dangers of Patient Hand-Offs
Another argument which many physicians and medical institutions give for justifying long shifts is the improved patient outcomes that come with continuity of care. They note that physician hand-offs (when a patient transfers from one physician to another at the end of a shift) are a dangerous time on the floor, as mistakes (such as failure to report lab results) can easily be made during report that can lead to poorer patient outcomes. Longer resident hours can help to minimize this problem and increase the needed continuity.
In brief, the controversy over whether or not residents should be working the traditional long shifts or whether those shifts would be shortened and more time given off, is still one which the medical community is trying to resolve. However, it is likely that more research will need to be done – particularly on the issue of whether increased physician fatigue can lead to an increase in poor patient outcomes – before more of a consensus (if any) can really be reached.
References
Comondore, V. et. al. The Impact of Sleep Deprivation in Resident Physicians on Physician and Patient
Safety: Is it Time for a Wake-Up Call? 2008. BMC Journal. 50:10 560-564
Gold, J. New Rules on Medical Residents’ Hours Sparks Debate. National Public Radio. 2011.
www.npr.org/2011/01/137532829/new-rules-on-medical-residents-hours-spark-debate
Mahan, M. Sleep Deprivation: Can Residents “Learn” to Function with Less Sleep? Health Beat. 2011.
www.healthbeatblog.com/2011/08/sleep-deprivation-can-residents-learn-to-function-with-less-sleep

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Brian Wu graduated from the University of Maryland with a Bachelor’s of Science in Physiology and Neurobiology, and graduated from the Keck School o...