A Lapse in Judgement
After two decades of talk about limiting first-year medical residents' work hours to ensure patient safety, a recent Harvard Work Hours, Health and Safety Study reveals that the problem persists -- lighter schedules reduced serious medical errors by 36%, yet most first-year residents continue to work more than 80 hours a week.
SLEEP MORE, ERR LESS
At Brigham and Women's Hospital in Boston, a Harvard Medical School teaching affiliate hospital, interns are typically on duty for 85 hours a week, including two extended shifts of 30 or more consecutive hours. In the Harvard study, interns were switched to "intervention schedules" in which they worked 65 hours a week, got an average of six more hours of sleep weekly and were on duty for no longer than 16 hours at a time. Christopher P. Landrigan, MD, MPH, director of the Sleep and Patient Safety Program at Brigham and Women's Hospital, followed up this study to determine if the new schedule reduced serious medical errors. His results were dramatic. First-year residents on the intervention schedule reduced the incidence of serious medication errors by 21% and serious errors overall by 36%. The errors ranged from overprescribing medication to inserting a tube into the wrong side of a patient's chest. Fortunately, most errors were caught in time and no patient suffered serious harm from them -- at least in this study. Who knows how many of the thousands of medical errors made per year due to exhaustion are not caught?
CHANGING THE CULTURE
Sleep deprivation is known to negatively impact performance, whether you're driving a car or treating a patient. Nevertheless, debate about long work hours continues to rage in the medical profession, with some conventionally trained doctors insisting that the experience is required for a "proper" medical education. Consumer advocate Charles B. Inlander, president of The People's Medical Society and author of Take This Book to the Hospital With You, notes that a kind of military thinking prevails in medicine: "I went through this to get to where I am today, so you should, too." Sounds almost like fraternity hazing, doesn't it? Yet somehow, when all data show otherwise, it is also a frightening rationale for people whose judgment we are to trust. The Accreditation Council for Graduate Medical Education (ACGME) has moved to impose an 80-hour workweek for all medical residency programs and a 24-hour limit on consecutive duty. While it does not seem like much, the improvements have to start somewhere. In many hospitals, even after lower standards for hours are imposed, residents typically continue to work 100 or more hours per week. With greater public awareness of medical errors by sleep-deprived interns, Dr. Landrigan's hope is that these shorter work hours will be legally put into place by Congress and strictly enforced.
WHAT YOU CAN DO
While the "old boys' network" fights it out, it is critical that you be your own best advocate. If you are hospitalized, Dr. Landrigan advises that you ask the doctor treating you the following questions...
*Are you a first-year resident?
*How long have you been on duty, and how much sleep have you had during this shift? (Actually, you may want to ask any doctor treating you how long they've been on duty, since there are other medical professionals, including surgeons and obstetricians, who also are held to extended schedules.)
If your doctor has been on duty for more than 24 hours with little sleep, speak up. Ask to be treated instead by a more experienced and, hopefully, less-fatigued doctor. Dr. Landrigan acknowledges that it is awkward to ask these questions and make this demand, but then again failure to do so may be hazardous to your health. Hopefully, one day the policy will change and an external body will monitor its enforcement so that you won't have to be placed in this situation. Following the highly publicized death of 19-year-old college freshman Libby Zion in a New York City emergency room in 1984 (and the subsequent lawsuit brought by her father, prominent journalist Sidney Zion), in 1989 the New York State Legislature enacted New York State Code 405 limiting residents' workweeks to an average of 80 hours per week over a four-week period. ACGME seeks to impose this limit on all medical residency programs nationwide. However, without some Congressional stamp of approval, whether these limits will be enforced is another matter altogether.