Help Train Future Physicians: Say Yes to Interns & Residents - Part 2

Recently, an air traffic controller at Washington Reagan National Airport failed to respond to radio & phone calls for 20 minutes or so.  Two days later, he admitted to having fallen asleep because he was working his fourth consecutive overnight shift.  What's not clear to me is whether he had worked four straight 24 hour shifts or simply switched to 4 consecutive night shifts without allowing for physiologic circadian adjustment.

I mention this because until recently, due to federal mandate, we (the medical profession) prided ourselves on our mental toughness and ability to go for days (and nights) on end w/o little-to-no sleep.  After all, when I trained many moons ago, it was common to be on call every other night during some rotations.  And to prove our machismo, we complained that we were disappointed because we would miss half the cases!

However, we have since learned that sleep deprivation is a bad thing that impairs both clinical judgment and fine motor coordination.  Most notably, the death of Libby Zion resulting from allegedly overworked & under-supervised resident physicians lead to the passage of work hour limits in New York in 1989.  This was followed by national work hour limits in 2002 so while the clock for overtime for most hourly employees starts after 40 hours worked in a week, we are now prohibited from allowing our residents to work more than 80 hours a week.  Back in the day (imagine chest thumping here), we routinely put int 50% more hours, spending most waking hours in the hospital without much conscious time outside (time off work was spent asleep getting ready for another shift).  In fact, my then-girlfriend-now-wife still recalls that I fell soundly asleep at the table during our first Valentine's Day dinner.

After I started teaching, the work hour limits came into play.  Academia struggled with how to balance these new regulations with providing quality care and a sound educational experience.  The initial solution was the attending physician filling in for the residents, enough so that my wife commented that I was working harder as an attending than as a resident!  So a new rotation (night float) was designed whereby one's only responsibility was to work nights for a month or two, covering overnight call for one's fellow residents.  But at what cost (some estimate as much as $1.6B annually) as another rotation's learning experience was sacrificed.

So here we are many years later and it's good to find out that, in a review of 72 studies published last month in the British Medical Journal, reducing the work hour limit to 80 hours a week has not made a negative impact on either patient outcomes or physician training.  Unfortunately, if you like your glass half empty rather than half full, the converse of this study is that patient outcome (read safety) hasn't improved either.  In Europe, there are already scattered attempts to further reduce work hours to a more humane 56 or 48 hours a week.  The jury is still out as we gradually step off our sleep pedestal and allow our residents the sleep we recommend for our patients.