When Your Doctor Is on a 30-Hour Shift
A new program has medical residents working for up to 30 hours without sleep in ICUs—putting patients in danger of hospital errors.
I cannot even count the number of times that I have been told by medical faculty members that nowadays “residents have it SO easy.”
Their tone indicates that they have clearly suffered more terrible work hours and conditions than any resident today, so complaints from our end should be stifled entirely. And accordingly so, I very seldom complain about the number of hours I find myself at work. Sure, it is rather unfortunate that most months I only get one day off a week and weekends are luxuries, but hey, I make the most of it.
Once I became a second-year resident, the former 16-hour cap to my workday was removed and replaced with a 24+4-hour workday cap. This is code for a full 24 hours in the hospital along with four hours afterward to wrap up any remaining work (read: 28 hours). This schedule is kosher and within work-hour restrictions imposed upon my residency program by the Accreditation Council for Graduate Medical Education (ACGME).
However, my internal-medicine residency program is also taking part in the iCOMPARE study, which is a randomized trial comparing hourly restrictions for residents against a more flexible policy. The more flexible policy effectively removes a daily cap from all internal-medicine trainees across the board, including first-year interns, and places a looser 80-hour maximum per week rule.
As my luck would have it, our residency program is applying this system to what is viewed as one of the hardest stints of the entire 36 months of our residency training: one month at the county hospital’s medical intensive care unit (MICU). Every four days, my three interns and I spend 30 hours in the hospital continuously covering the MICU: handling patients, accepting patients from the general medicine wards who are clinically deteriorating, and admitting new, critically ill patients from the emergency room.
Residency work hours have always been a controversial topic, with discussions of the tradeoff between safe working hours for physicians and patient safety. The iCOMPARE study has also recently been the source of significant controversy, as many argue that the study pushes physicians beyond reasonable limits and may also very negatively affect patient safety. Sleepier doctors mean patients could be at higher risk for adverse events—makes sense, right? It does, until you realize that shorter work hours also mean more handoffs between doctors coming and going. More physician handoffs open the way to miscommunication problems, so it may boil down to choosing the better of two evils.
In 2010, a survey found that the American public, better known as our patient population, voted overwhelmingly in favor of discontinuing consecutive 30-hour shifts and reducing work hours to 16 or fewer hours for resident physicians. One could easily argue that provider lack of sleep and physician fatigue could be far more dangerous for patients than miscommunications at the frequent handoffs.
Our county hospital is one of the biggest in the country and our patients are some of the sickest I have ever seen, so you can imagine that no 30-hour call goes by easily. When my team is on call, we nap in shifts as is feasible—and on most nights, napping in shifts means we all may get an hour of sleep if we’re lucky. It’s no surprise that a small study done in 2015 that looked at young doctors working night shifts found that sleep-deprived doctors performed poorly on psychomotor testing. Sleep-deprived doctors also had more errors on those tests when compared to non-sleep-deprived doctors in the same study. Another, even more concerning study looked at doctors working nights in intensive care units and found that cognitive performance declined across the board, regardless of physician level of training or amount of nap time obtained, after a night shift in the ICU. I imagine no patients would want medical attention from physicians who have decreased working memory capacity, speed of information processing, perceptual reasoning, and cognitive flexibility—all of which deteriorated after night shifts.
More often than not, medicine is a 24/7 career. Even when we’re not at work, we’re often thinking about our patients, and while we often have no choice regarding the hours we work, particularly doctors-in-training, perhaps it really is unethical to subject our patients to sleep-deprived doctors without giving them any say in the matter.
I will be able to overcome the most exhausting month of my training as soon as I bank away some extra nights of sleep, but will I ever be able to forgive myself for errors I might commit because of this exhaustion while on the job? Probably not. And most certainly not if these errors place my patients at risk. There has to be a better way to balance both physician well-being and patient safety, and I can guarantee you that “flexible duty hours” are not the answer. But ultimately, only time will tell if the iCOMPARE study results validate my personal opinion.