Newsflash: Doctors Are Human Too

After 10 hours on the job, a truck driver must pull off the road. After 16 hours, an airline pilot can no longer legally fly a plane. But after 24 hours or more on the job, with perhaps an hour nap somewhere along the line, a first-year medical resident can perform a surgical procedure, write a prescription, or insert a chest tube.

This introduction to a 2004 article in Focus Online, the newsletter from Harvard Medical, Dental, and Public Health Schools, says it all: we expect doctors to be superhuman.

When you stop and think about it, the expectation that medical residents, especially first-year interns, can, or should, perform incredibly complex procedures with minimal sleep is crazy. Medical researches agree—which is why hospital shifts of doctors-in-training have come under much scrutiny in recent years.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) created standards to restructure residents’ hours in order to combat fatigue, and the dangerous mistakes that accompany exhaustion. The council’s reforms limited residents’ hours to:

• No more than 80 hours a week
• No more than 6 work days a week, averaged over 4 weeks
• No more than 24 continuous hours of duty, except for another 6 hours of education or transfer of care In-house call no more often than every third night
• No less than 10 hours of rest between duty periods

These changes were meant to benefit not only residents, but also patients: an exhausted doctor is a careless doctor. But for all of the Council’s good intentions, studies show that the ACGME reforms don’t go far enough—residents need more of a break if they are to maximize their effectiveness and ensure the safety of their patients.

How do we know?  Last year, two studies from Kevin G. Volpp, MD, PhD, from the Center for Health Equity Research and Promotion, VA Hospital in Philadelphia, Pennsylvania looked at whether the first four years of the ACGME guidelines had resulted in a meaningful decline in patient mortality—in other words, if the guidelines had saved lines by keeping doctors alert and rested.

Unfortunately, after looking at 318,636 VA patients from June 2000 to June 2005, and a whopping 8,529,595 Medicare beneficiaries over the same period, Volpp found that “the overall impression remains that duty hour restrictions have had little effect on patient mortality.” For the VA patients, there was a slight improvement in mortality after the introduction of the ACGME guidelines, but not for surgical patients. Volpp’s Medicare study showed that “the ACGME duty hour reform was not associated with either significant worsening or improvement in mortality.” According to Volpp, these mixed results mean that there is still “controversy about whether the current duty hour rules are sufficient for regulating work hours."

This last sentence is key: the problem with ACGME reforms isn’t that reducing resident hours is a bad idea, but rather that the guidelines don’t go far enough in restructuring schedules. Again, the question must be asked: how do we know? 

A 2004 study by a Harvard Medical School (HMS) team led by Charles Czeisler, the Frank Baldino Jr., PhD professor of sleep medicine at Brigham and Women's Hospital, compared the ACGME paradigm to an even more flexible one they designed—and found that, when it comes to resident shifts, less is more.

Czeisler’s team followed “20 interns [who] completed two three-week rotations in the intensive care unit,” and divided the interns into two groups.  One group followed the ACGME guideline of 80 hours a week (although in practice, “nearly all interns” worked at least 80 hours), and the other kept to a revised schedule which allowed a maximum of 16 continuous hours of work at a time, for a total of around 65 hours per week. (This revised schedule was called the “intervention schedule” in the study).

Here’s a run-down of the study’s methodology and results, courtesy of Focus Online: “The interns logged the hours they spent sleeping and were monitored at work and at home with electrodes to record eye movements and brain waves. On the intervention schedule, interns averaged 5.8 hours more sleep per week and experienced less than half the rate of ‘attentional failures’ at night, slow-rolling eye movements caused by profound sleepiness during waking activities at work.”

As unimpressive as the absence of “slow-rolling eye movements” may sound at first, in reality it’s critical that residents be well-rested (as we’ll soon see). In a follow-up study, Christopher Landrigan, an HMS assistant professor of pediatrics, led a team that looked at the Czeisler’s intervention schedule in order to determine whether it reduced serious medical errors. Rested interns are all well and good, but what really matters is whether or not rested interns screw up less. Once again, Focus Online summarizes the methodology and findings:

“A team of observing physicians (working in eight-hour shifts) shadowed the interns at all times over the course of their rotation through the intensive care unit. The observers recorded and categorized every error that the interns made, and the results were verified by two physicians who were unaware of the schedule the interns were following. The study found that interns made 35.9 percent more medical errors considered serious during the traditional [ACGME] schedule, including 20.8 percent more medication errors  and more than five times as many serious diagnostic errors].”

This is scary stuff, and the major problem seems to be that the ACGME shift framework is still too darn demanding—especially because it allows for 30 hour continuous shifts.

In a more recent study, Harvard’s Czleisar was part of an American and Canadian team of medical researchers who tracked 2,737 interns via web surveys where they “gave information about their working hours, hours of sleep, and number of extended-duration shifts [i.e. at least 24 hours continuously at work]…and completed questions about medical errors in the past month. Then, for each intern in the study, researchers compared month by month the number of medical errors and the number of extended-duration shifts that had been worked.”

The researchers found that months heavy on extended-duration shifts were also heavy on medical errors. When “compared to months in which no extended-duration shifts were worked,” it turned out that in  months where an intern completed between one and four extended-duration shifts  researchers were 3.5 times as likely to see “at least one fatigue-related significant medical error.” And in months when an intern worked five or more extended-duration shifts, this probability shot up 7.5 times—meaning there was a 750 percent greater chance of major screw-ups in the five-times-or-more extended-duration months than in those without extended hours.

Equally shocking are the studies’ numbers on “fatigue-related preventable adverse events.”  In months where a resident worked extended-duration shifts, the probability of these events increased anywhere from 700 to 850 percent! Most strikingly, “interns working five or more extended-duration shifts per month…reported 300 percent more fatigue-related preventable adverse events resulting in a fatality.” Thus, quite literally, medical shifts place patients’ lives on the line—and if a resident is too exhausted, patients can lose out big-time. Lo and behold, doctors are human—indeed, all too human.

Given all of this data, there seems an obvious conclusion: if a tired resident is a dangerous resident, why not just put strict limits on their work hours?

There are many reasons why we need to be careful about cutting medical shifts. For one, medicine will always be a high-endurance profession, no matter how resident shifts are structured. Some surgeries can take thirteen or fourteen hours to complete, and the unexpected is routine in hospitals and emergency rooms, meaning that stamina is of the utmost importance. Pampering residents with neatly bounded shift schedules won’t provide adequate preparation for the reality of being in the trenches.

Another reason we need to be careful in chopping up shifts is that the doctor-patient relationship is both important and sensitive. A “punch the clock” system of medicine, where providers check in and out regardless of what’s going on with their patient, is no more desirable than a marathon framework. Do you really want your doctor checking his watch during surgery?

The last concern is that the more switches there are, the more often patients are handed-off, i.e. transitioned from one provider to another. Hand-offs are dangerous moments, where miscommunication can lead to serious problems for patients—something which I’ve discussed in the past.

But there’s a huge middle ground between an 80 hour work week and too many punch-the-clock hand-offs.

The Internet might be of help here—if virtual medicine is in fact all its cracked up to be, shifts could become less labor intensive. Perhaps, some day, some of what goes on in hospitals today can be done online. But that’s a ways off, and until we enter that wired utopia, the best we can do is go through a process of trial-and-error in structuring medical shifts.

The two main variables to be adjusted are the total hours worked per week and the length of a continuous shift. In both cases, there’s a lot of room to experiment. In 2004, for example, Brigham and Women’s Hospital, (BWH) where the HMS studies were centered, instituted 12-hour shifts—less than half as long as the common 30 hours stints—and 12 hours off between shifts.

These changes brought BWH more in line with Europe, where junior doctors don’t work more than 13 hours. The European Working Time Directive also limits junior docs to a total of 56 work hours per week, with that number to be reduced to 48 hours by next year.

It’s hard to say where the sweet spot is in terms of resident scheduling. But the data on current shift guidelines makes one thing crystal clear: we’re not quite there yet.

Comments

[Lisa Lindell]

What would happen if nobody voted, not one single person. I know it's not likely to happen, but seriously, if not one vote was cast, what would happen?

[Lisa Lindell]

I think we all, consumers and health care providers, need to organize effectively and shut down our health care system. We need to keep it shut down until it's open for business in our vision. Somebody suggested we make our voice heard when we vote. I'm not bad mouthing the democratic system of voting, of course, but when you vote you're choosing "the best offer" in your opinion, and trusting said candidate will make good on their offer. I think the health care system needs to be built in our vision, by the people and for the people. If this were organized and supported with enough numbers, this could be successful swiftly and without casualties. Congress convened swiftly for Terry Shiavo, you think they won't if millions of doctors, nurses, paramedics, etc walked off the job? If every consumer refused to make another purchase from any US pharmaceutical company? Of course they will. I say to Hilary, Obama and the others to put your offers in your Farfanugen and smoke 'em, this is what I demand from you:
You will not force me, a working American with a $42k a year salary that doesn't use credit and has no debt other than a mortgage on a $120k house and one car payment on a modest Chevy pick up, to choose between paying my mortgage or taking my child to a doctor when he's sick.
You will no longer force me to raid my bathroom for expired ABX when my husband, who is supposed to be covered by insurance, gets pnuemonia as he often does due to a disastrous hospital experience.
You will allow me to stay with my child/spouse/parent when they are hospitalized, 24/7, if the pateint so chooses.
You will respond and act appropriately when myself or my child/spouse/parent suffers from abuse and/or neglect when receiving medical care.
You will mandate universal standards of safe care, treatment and ethics and enforce same.
You will outlaw financial incentives "gifts" in excess of $100 to providers from all medical suppliers (attn pharmaceutical firms, this means you)
You will not dare "order" me or any other American to purchase insurance for health care. You will not dare "order" me or any other American to improve the bottom-line of a for-profit health insurance company.
Driving and operating a motor vehicle is a priveledge, if you want that priveledge, there's certain rules you must abide by, like having a license and having insurance. How dare you try and force me to purchase a defective product (health insurance) so I can pay for a defective product (health care treatment). Have you been paying attention? Insurance companies aren't in business to pay claims. Are you telling me, this American, that if I'm sick or injured you're going to let me rot if I don't follow your rules? Are you telling me, this American, that the endemic and HIGH RISK of acquiring an infection while hospitalized is acceptable to you? Are you telling me, this American, that indentured servitude (resident working hours) is acceptable to you? Are you telling me, this American, that neglect and abuse by health care providers is permissable to you? Are you telling all of us Americans that profits are more important to you than the health and safety of our own citizens, the future of our nation? And Hilary to you especially, I know my book was delivered to your staff in the diplomatic pouch a very long time ago, by a friend of yours. Shame shame shame on you for not shining a very bright light on the disaster and embarrassment that is the American health care system. It could have carried you all the way to the White House, sister.

[anonymous]

i think as well that people who have been working around recent graduates definitely see a decline in their skill level, both cognitive and procedural. the duration of the residencies may need to be extended to allow them time to mature, as unpopular as that might sound to medical students. that might alleviate some of the 'loss' of workforce.
perhaps that might allow some of the time the attendings lost for teaching during institution of the 80 hour workweek to be returned to them. hah!

[drmatt]

There is a point that no one seems to mention. What about non resident docs, some of them are working many dangerously long shifts without oversight?

The arguement for making residents work so much has been presented to me like this. It is unpredictable during residency which disease processes will walk through the door (in residency we talk disease not people). So in order to "maximize" your educational experience you need to be here as much as possible.

My retort has always been, If I am not sleep deprived I won't need to see 20 pneumonias to learn how to manage them, I could do it with 5 or 10. All the studies show that sleep deprivation decreases our ability to learn and learn efficiently.

When the ACGME changed the rules (under pressure from congress) to a mere 80 hrs a week, the faculty was angry and often took it out on residents (we had to do it, why shouldnt you). It is a hazing, pure and simple. Further more I am aware of many residencies where the pressure from above is, "I can't tell you to work more hours, but let's just say you will be frowned upon if you don't", oh and report that you didn't work more than 80 hours and I won't double check you. Dont be to sure that the residencies are complying fully with this standard.

In the end this is pure and simple economics, docs cost too much to have two separate shifts. Note, however, that we dont do this anywhere else that requires 24 hour coverage, police, fire, security, nursing etc. etc. etc.

[dan walter]

No Kidding:

http://adventuresincardiology.wordpress.com/

[Rob]

I have wondered about this for years. What is the purpose of making someone dangerously tired? Is it a form of hazing ritual? Is it "toughening" them up? Is it so that if someone is the only doctor aboard during a plane crash on a desert island s/he can stay up all night keeping the invisible mutant animals away with a torch?

Ok, maybe I go too far, but I can't help but think this is about economics - it's cheaper to spread interns thin. Surely there's a way to do this without putting everyone in danger from a massive sleep-deprivation experiment. Isn't there a better way?

Trucks still get driven. Trains and planes still go their routes. Why do we expect doctors to be able to perform 30-some hours in a row when, ironically, medical research can tell us how dangerous that is.

Maddening, it is.

[Ken Cohn]

Glad to see both sides of the coin represented re: handoffs and given current shortages of personnel, how do we staff optimally?

What is lacking from all these safety studies is carefully controlled studies of what constitutes the ideal learning experience: how many patients do residents need to see to obtain the spectrum of knowledge to understand variation in symptoms, treatment, and complications?

[robertdfeinman]

If interns were allowed to organize effectively the "optimum" would soon emerge as the result of collective bargaining.

Most top down studies neglect to seek input from those they study. It is as disastrous in foreign aid as in medicine.