After having their work days limited to 16 hours for the past six years, first-year medical residents in teaching hospitals like Greenville Memorial will once again be permitted to work 24-hour shifts — plus four hours for paperwork — beginning in July.
The Accreditation Council for Graduate Medical Education, which instituted the change, says it’s necessary for continuity of care and the education of residents — physicians often must work extended periods to admit, stabilize and hand off critically-ill patients.
But outraged consumer and patient safety groups say the change will lead to more medical errors as over-worked and bleary-eyed residents succumb to the effects of sleep deprivation.
Medical error is the third leading cause of death in the U.S. after heart disease and cancer, accounting for more than 250,000 deaths each year, according to researchers at Johns Hopkins University.
And each year some 12 million adults, or one in 20 people, are misdiagnosed, resulting in serious problems such as delayed cancer treatments or unnecessary treatment for nonexistent conditions, according to research by Dr. Hardeep Singh of Baylor’s DeBakey VA Medical Center for Innovation in Quality, Effectiveness and Safety.
Patient safety activist Helen Haskell, who founded the Columbia-based Mothers Against Medical Error after the death of her 15-year-old son Lewis Blackman as a result of medical error, said increasing work hours will subject the residents to sleep deprivation that will affect their abilities.
“People can persuade themselves of all sorts of things. But in the end, human biology trumps all,” she said. “Young doctors are not immune to biology. There are serious patient safety concerns here.”
Haskell said the conventional thinking is that working long hours makes doctors more capable of dealing with emergencies and other medical cases. But the problem with that, she said, is that patients are put at risk in the bargain.
“Workload is a huge issue and there’s not always a lot of back-up,” she said. “It’s extreme sleep deprivation. And it goes on for years. Even 12-hour shifts are too long in that context.”
‘Do no harm’
The public overwhelmingly opposes the increase in hours, said Dr. Sammy Almashat, a researcher with Public Citizen’s Health Research Group, which conducted a nationwide poll that showed 86 percent were against it. A similar number said they’d want another doctor if their own had been working more than 16 consecutive hours without sleep.
“What residents experience working shifts of 28 hours is sleep deprivation ... (which) affects decision making, cognitive skills and memory,” he said. “And doctors should know more than anyone else the detrimental physical and mental effects of sleep deprivation.”
Besides Public Citizen, groups opposing the change include the Committee of Interns and Residents, the National Physicians Alliance, Consumers Union, as well as dozens of other patient and consumer groups.
“It is such an awful policy — none of us would get on a bus driven by someone working these hours or pay a drowsy electrician to wire our house,” said Lisa McGiffert, director of Consumers Union’s Safe Patient Project, which says fatigue-related medical errors put patients at risk of injury and death.
“Why would people tolerate this if they knew about it?” she added. “Unfortunately, people in the hospital often don’t know who is working on them.”
The American Medical Student Association also wrote to ACGME, urging that the 16-hour limit be kept for all residents, saying that increasing hours compromises both patient and physician safety.
“Research has shown that acute and chronic sleep deprivation are detrimental to learning, which is in fact a primary goal of residency training,” they said. “We have a responsibility to ensure that we keep patients and trainees from harm, while providing the best care that we can. AMSA is urging the ACGME to ensure that we do no harm to patients or to our trainees.”
Consumers Union, which joined the call for reduced hours after an Institute of Medicine report on resident duty hours, said the 16-hour work limit was an improvement over previous shifts, but didn’t go far enough to protect patients.
The ACGME, which oversees the professional preparation of new doctors, acknowledged that work hours provoke great emotion “in both the graduate medical education community and among segments of the general public,” adding that it got statements from more than 120 organizations and individuals.
But it said the expanded hours serve the best interests of patients and residents to provide a more realistic view of medical practice.
"The necessity for physician education to simulate real-world practice cannot be overemphasized," they said. "Just as drivers learn to drive under supervision on the road, residents and fellows must train in real patient care settings for the situations they will encounter after graduation.”
“The main reason for the changes in the learning and working environment is to enhance patient safety, quality of care and well-being of doctors in training and the faculty teaching them,” said Dr. Rowen Zetterman, chair of the ACGME Board of Directors. “The new standards put first-year residents on the same schedule as other residents, improving continuity of care and team-based care.”
Zetterman added that the total hours that residents may work in clinical care will not change from the current 80 total hours in a week, one day off every seven days, and no overnight in-hospital call more often than once every three days.
Residents also have sleeping rooms when they need them, he said, and 24 hours is a floor, not a ceiling, with flexibility across specialties to adjust as needed within the maximum. Many residents, particularly in specialties like emergency medicine, will never work 24 hours, he said.
In making the decision, ACGME sought advice from multiple medical organizations and reviewed trials that compared up to 24 hours of active clinical care to the current requirement of 16 hours, he said.
“If a resident feels that their fatigue interferes with their ability to deliver appropriate patient care, their training program is required to have a mechanism to allow that resident to transfer patient care to another physician,” he said.
“No one wants a tired doctor," he added. "Residents provide care under supervision and can always hand off patients to other care providers, if necessary."
As a surgical resident in the 1970s, Dr. Jerry Youkey, dean of the University of South Carolina School of Medicine Greenville, worked some extreme hours.
“There were multiple times where I know I was working hours or fatigued beyond what was a good idea,” he said. “There was one stretch where I was actually almost constantly in the OR for about 48 hours.”
It was Thanksgiving and his wife had prepared a lovely dinner for them and their guests, he said. But instead of joining the festivities, he walked in the door, apologized and fell into bed.
Nonetheless, Youkey said that regulating hours isn’t the way to keep overtired doctors — all of them, not just residents — from working. It should be peers, nurses, attending physicians and the doctors themselves who take themselves out when they’re too tired to function well, he said.
“The issue isn’t how many hours, but what you do and how fatigued you are. It’s something we should be looking at,” he said. “It (restricting hours) really in many ways usurps
the ability and responsibility for the care providers to be making safety decisions based on circumstances.”
While 28 hours worked continuously is taxing, most people are on call during that shift and sleep part of the time, he said. And, he added, the regulations don’t take into account what the doctor may have done during his time off and may actually allow people to disregard signs of fatigue because they haven’t hit the maximum.
Greenville Health System makes a concerted effort through training to ensure that medical students, residents and doctors understand they shouldn’t work beyond a level of fatigue and stress, Youkey said. And residents must check in with their program directors to log hours.
“There is no question in my mind that if you don’t pay attention to signs of fatigue, you will get unsafe situations,” he said. “But you can’t regulate safe care.”
Peaks and valleys
Youkey said patients have peaks and valleys, and that it’s beneficial for residents to see patients throughout their illness.
“If you have to go home when you don’t know what the outcome was of the treatment, it isn’t as good for education,” he said.
But Almashat said that most of what he learned as an internal medicine resident occurred in the first 12 hours.
“As you get tired, you can’t absorb it anyway,” he said.
While learning ability deteriorates after a short period in the classroom, it’s different in the clinical setting, Youkey said.
“You will continue to learn things as you take care of patients, whether as good as after two hours or 10 hours, I don’t know,” he said. “But the point is you’re learning from a patient’s illness and progress.”
Almashat said the number of errors tied to sleep-deprived residents, which is not recognized in any data, is likely vastly underestimated.
One of the main concerns about shorter shifts is handoffs — times when a patient’s care is being transferred to another doctor and problems can arise, Youkey said.
“Every time there’s a handoff, there’s some risk of information not being transmitted and losing continuity of care. The shorter the work hours, the more frequent the handoffs,” he said. “And ... you don’t get to choose the course of disease at the time of the handoff. It’s bad idea to hand off during critical period.”
Almashat said there has to be a handoff at some point and nobody is arguing that residents should stay indefinitely — they have to leave sometime so there’s always going to be a handoff.
“You don’t want sleep-deprived residents making decisions or handing off patients,” he said. “You want well-rested residents who have a supervised standardized handoff system.”
Consumers Union said research shows that reducing shifts to 16 hours or less reduced the frequency of serious medical errors despite an increase in the frequency of patient handoffs.
In making its decision, ACGME said two studies — the FIRST trial for general surgery and the iCOMPARE trial for internal medicine — suggested that the 16-hour cap “may not have had an incremental benefit in patient safety, and that there might be significant negative impacts to the quality of physician education and professional development.”
But Almashat said the trials were poorly designed with a predetermined outcome. Haskell agreed.
“This is not being based on good evidence,” she said. “That’s a concern.”
A number of studies show that residents make more medical errors when working shifts of 16 hours or more, Almashat said. And the definitive study, done by Harvard researchers in 2004, concluded that those working 24 hours or longer without sleep made about 36 percent more serious medical errors than those working 16 hours or less, he said.
There are also impacts on the residents expected to work 80 hours a week for three to seven years, he said.
“Residents have more depression, needle stick injuries that expose them to blood borne infections, and are more likely to have a car accident driving home that puts them and the public in danger,” he said.
“Medical residents are not superhuman,” said Dr. Michael Carome, director of Public Citizen’s Health Research Group, “and when sleep-deprived, put themselves, their patients and others in harm’s way.”
Almashat said residents are “free labor” for hospitals because Medicare pays their salaries, which range from $50,000 to $70,000 a year, plus an additional subsidy of $80,000 to $100,000 per resident to teach them.
“That’s what academic hospitals have been doing for decades,” he said. “They have an interest in keeping hours as long as possible because otherwise they’d have to hire others to make up for the loss of hours.”
But Youkey disputed that, saying economics isn't a consideration.
“When it comes to taking care of patients at the bedside, people don’t think that way,” he said. “There are (administrative) policies that get made outside the clinical setting. But nobody (physicians) thinks bout it from an economic standpoint.”