Are Medical Residents Worked Too Hard?

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There has been much hand-wringing over the dangers of medical residents' grueling schedules. Doctors-in-training often forgo sleep entirely, racking up as many as 30 work hours in a single stretch. The term resident is in fact no accident, says Dr. Teryl Nuckols, an internist and assistant professor at the David Geffen School of Medicine at UCLA, who says that when she was in training 10 years ago, 36-hour shifts without rest were common. "[Residents] used to live in the hospital," Nuckols says. "They were there 24/7."

The issue is whether their presence, dizzy with exhaustion, on the hospital floor is a help or a hazard. An oft cited 2004 study of intensive-care units found that medical residents made 36% more serious mistakes during 30-hour shifts than during shifts half as long. So the simple solution to ensuring patient safety — and resident sanity — would appear to be reducing the length of their shifts, a plan endorsed by a lengthy Institute of Medicine (IOM) report in December 2008 that assessed the impact of resident fatigue and proposed a new set of guidelines restricting shifts to 16 continuous hours if no rest is granted, mandatory uninterrupted five-hour naps for longer work sessions, lighter workloads and more oversight from experienced physicians. (The current standards set in 2003 by the Accreditation Council for Graduate Medical Education, or ACGME, mandate 80-hour average workweeks, with no shift to exceed 30 hours.) (See the most common hospital mishaps.)

"If you follow our report and put it into practice, residents would have greater opportunity to get more sleep," says Dr. Michael M.E. Johns, chairman of the residency-optimization committee at the IOM and chancellor of Emory University. "[Residents] would also have increased supervision by experienced doctors."

But many in the medical community, including residents themselves, worry that shorter shifts could come at the expense of educational opportunities and possibly even patient safety. And implementing the changes wouldn't be cheap, potentially costing teaching hospitals $1.6 billion a year, according to a study co-authored by Nuckols and published this week in the New England Journal of Medicine. (Watch TIME's video "Uninsured Again.")

Instituting the measures could be a boon for society, however, potentially reducing the overall price of errors — e.g., subsequent hospital visits, extra posttreatment care and lost wages — to almost negligible levels, but only if the new policies can decrease the rate of preventable errors at least 11.3%, according to the study. (See the top 10 medical breakthroughs of 2008.)

"Medical errors are expensive, and most of the costs of medical errors actually affect people after they leave the hospital," says Nuckols, who is also a health-services researcher for the Rand Corp., the nonprofit health-research group that sponsored the study. "If the recommendations do succeed at reducing medical errors, there could be some cost offsets."

There is no guarantee, however, that limiting residents' shifts is the key to patient safety. Dr. Kenneth Polonsky, chairman of the Department of Medicine at Washington University in St. Louis, who co-wrote an editorial accompanying Nuckols' study in the New England Journal, says that while some studies show a correlation between fatigue and mistakes, not all reach the same conclusion. What's more, Nuckols says, studies aimed at determining the cause of a mistake are inherently complicated: they require highly skilled researchers to pinpoint exactly what went wrong and when, and many rely on self-reporting from residents who, for obvious reasons, would sooner attribute a mistake to exhaustion than to other factors.

See the top 10 medical breakthroughs of 2008.

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