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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.
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Polonsky also points out what he deems faulty, nonanalogous logic sometimes used by advocates for shorter shifts, who liken residents' work regulations to those for commercial pilots, who are similarly prohibited from flying more than a maximum number of hours in a stretch. "If you think of what is really proposed [by the IOM], it is like having a pilot switching over in midflight or asking him to switch over as he's about to land," he says. "'Well, your time is up, it's time for someone else to take over.'"
Defining residents' shifts solely by the tick of the clock means that more patients could end up being handed off from one doctor to another at inopportune moments, and research suggests that those handoffs are when errors may commonly occur. "If we do something like this," says Polonsky in reference to the IOM's proposed guidelines, "I want to be sure that it is primarily going to improve the outcome of our patients," and then adding, "But that's not necessarily the case here."
Even medical residents are wary of the proposed changes, and some are reluctant to give up their exhausting schedules, which many deem necessary for learning. Dr. Erika Roshanravan, a first-year resident in the family-medicine program at the University of Washington in Seattle, agrees that getting more sleep is crucial but thinks it makes little sense to mandate a five-hour nap in the middle of a shift. With patients' cases still fresh in the mind, and with the awareness of having get back to work soon, Roshanravan thinks few residents would actually get any rest. A better solution would be to shorten residents' workweeks while lengthening the term of the residency overall. In Roshanravan's native Switzerland, where she attended medical school subsidized by the government, she says the family-medicine specialty takes five years, not three as in the U.S. But that would require an even longer postgraduation period of low pay and accrual of debt in this country. "I don't think people want to have to wait to pay off all of that debt," says Roshanravan.
Dr. John Scales, a first-year resident at the University of Florida who will begin his training in radiology this summer, says more sleep would enable him to better retain everything, "to consolidate some of the learning that happens on an almost daily basis," he explains. But he worries that more mandatory rest could mean missed educational opportunities. "More days off always sounds nice, but it distances us from what is going on in day-to-day patient care. A lot can change in 24 to 48 hours," he says.
Indeed, the resident's labor-intensive schedule was not structured that way by chance, says Dr. Thomas J. Nasca, chief executive officer of ACGME. Learning to work through exhaustion is part of the training process, not merely a matter of young residents paying dues or getting hazed by veterans. "This is not indoctrination," he says. "It isn't a fraternity."
Too often, says Nasca, the debate is oversimplified to, "Would you like a doctor who is not fatigued?" But the real question is in fact more nuanced: "Do you want a competent physician who knows you to treat you, even if he is fatigued?"
Nasca is in the difficult position of helping set the rules for accredited residency programs in the U.S. ACGME held a conference in March to solicit the input of medical professionals and educators from around the globe, and in June it will host an event in Chicago in which 55 groups will present position papers on the subject. After that, an ACGME task force will meet every six weeks until the details of a new plan can be hammered out.
The issue is a complicated one, and resolution will not come easily or quickly, but policymakers and clinicians agree that increasing patient safety is the ultimate goal. "The key is that we don't want to injure patients," Johns says. "What can we do to make sure that even if [physicians are] fatigued, they can still perform at 100%? Let's do that study."
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- Tiffany Sharples