When you think of the rigors of medical training, what’s the first thing that comes to mind? I’m guessing you conjured the image of a sleep-deprived young resident roaming a late-night hospital corridor, fighting through fatigue in order to see her next patient. The notion of this sleepless rite of passage for doctors-in-training is deeply entrenched in our medical school culture, and has been reinforced by decades of TV medical dramas.
The truth is that sleep deprivation actually inhibits residents’ learning, and makes them more likely to make errors that can harm their patients. That’s why this news is so important and so welcome: This month, changes went into effect that limit the amount of time first-year residents can spend working without time off. These changes are a partial implementation of recommendations made by the Institute of Medicine (IOM), which conducted a comprehensive study in 2008 on the effects of resident physicians’ hours on medical errors.
Previously, residents were able to work as long as 30-hour shifts without time off, and up to a total of 80 hours per week. Residents may still work as much as 80 hours in a week, but first-year residents can work a maximum of one 16-hour shift before they must take off at least 8 hours. Second and third-year residents are able to work up to 28-hour shifts without time off, but they may not take on new patients after the 24-hour mark. While this sounds crazy, it is actually an improvement!
Depriving our doctors of sleep as part of their training is unhealthful for physicians themselves, and it can be downright dangerous for their patients. Medical errors are an enormous — and expensive — problem in our health-care system. Estimates vary greatly, but it’s clear that tens of thousands of patients suffer the consequences of medical errors each year. There is strong evidence that residents who work extended shifts are far more likely to make medical errors:
- One study showed that interns made 35.9% more serious medical errors while following a traditional extended-shift work schedule than when they worked a shorter schedule with longer breaks between shifts.
- While working extended shifts, first-year residents in another study demonstrated a significant increase in fatigue during lectures, rounds and clinical work, as well as 300 percent more preventable errors that resulted in fatalities.
- Extended work shifts have been shown to pose a safety hazard for residents themselves. One study revealed extended work shifts significantly increased their likelihood of getting in a car accident on the way home from work.
You don’t have to be a sleep-deprived medical student to know what happens to your body and your brain when you don’t get enough sleep. Sleep deprivation has mental and physical consequences that can significantly impact our ability to function:
- Sleep deprivation causes the brain to actually shut down in certain regions: this causes sluggishness, slows reaction time, and clouds judgment.
- Deprived of sleep, we’re also hampered in our ability to learn — and to convert our new learning into long-memories.
As the hours pile up without sleep, residents are less and less able to retain the information they need to learn, and less able to make smart — and safe — choices for their patients.
Nowhere is the image of the sleep-sacrificing doctor-in-training more entrenched than inside the medical community, and these changes have brought with them debate and resistance from some medical professionals who argue that the shift restrictions do not allow new residents to build the endurance they’ll need in their careers, and also will bring burdensome financial costs to hospitals. Others welcome these changes, but suggest they do not go far enough. (The general public is overwhelmingly in favor of limiting the work shift hours of residents in their hospitals.)
Count me among those who believe there’s still work to be done here. Limiting first-year residents to 16-hour shifts is a start, but what about extending those restrictions to all residents? This is just one of the recommendations made by the Institute of Medicine. The IOM also recommended:
- Increasing limitations on how often residents can be on-call without time off
- Extending time off between shifts to a minimum of 10 hours, with longer minimum breaks after night shifts or extended shifts
- Limiting the frequency of overnight shifts, and ensuring extended time off after several consecutive night shifts
Clearly there’s more to be done. But this month’s changes are an important step in the right direction toward getting hospital physicians the sleep they need to care for us to the best of their ability.
Michael J. Breus, PhD
The Sleep Doctor™
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