If patient safety matters, why are residents returning to long, sleepless shifts?

doc-sleep-300x225Must doctors be absolutely impervious to common sense improvements in the way they train their own? Their bullheadedness has reemerged with the revisited decision by a major academic credentialing group to allow medical residents yet again to work 24-hour shifts.

The Accreditation Council for Graduate Medical Education clearly was on the defensive when it issued its memo on residents’ learning and working hours, guidance that academic medical centers and hospitals nationwide will rely on in setting workplace standards for the young doctors in whose hands so many patients will put their lives. The council noted that it had established a high-level task force to reconsider criticisms of residents’ stress and overwork and how this might imperil patient care, responding to an early rollback of shift hours:

“… The Task Force has determined that the hypothesized benefits associated with the changes made to first-year resident scheduled hours in 2011 have not been realized, and the disruption of team-based care and supervisory systems has had a significant negative impact on the professional education of the first-year resident, and effectiveness of care delivery of the team as a whole. It is important to note that 24 hours is a ceiling, not a floor. Residents in many specialties may never experience a 24-hour clinical work period. Individual specialties have the flexibility to modify these requirements to make them more restrictive as appropriate, and in fact, some already do. As in the past, it is expected that emergency medicine and internal medicine will make individual requirements more restrictive.”

But over at KevinMD.com, a site where practitioners share their actual experiences in medicine, the new memo on long hours for residents is described under the headline, “The secret horrors of sleep-deprived doctors.”

Doctors write about working not 24 but 40 hours straight, and on 110 to 120 hour per week residencies, where they, “got to witness colleagues collapse unconscious in the hallway during rounds, and I recall once falling asleep in the bed of an elderly comatose woman while trying to start an IV on her in the wee hours of the morning.”

Another MD writes anonymously: “I have made numerous medication errors from being over tired. I also more recently misread an EKG because I was so tired I literally couldn’t see straight. [My patient] actually had a subarachnoid hemorrhage, and by misreading the EKG, I spent too much time on her heart and didn’t whisk her back to CT when she came in code blue. She died.”

Discussing guidelines and memos that seek to protect doctors in training from abusive schedules, one physician observes: “As a resident in a surgical specialty, my program routinely violated work hours, yet our attending physicians kept talking about how lucky we are because we have ‘work hour restrictions.’ ”

Another says:  “A dear friend from med school died during her neurosurgery residency. Drove over a median into a tractor-trailer after a 30+ hour shift. She left behind her family, including a twin sister and her fiancé. She was 30.”

The KevinMD anecdotes are devastating, and, as I have written, they are part of considerable research and evidence that beating up young docs by keeping them sleepless and exhausted makes no sense. It fails to address a problem in hospitals’ medical practice—issues in the “hand-over” of patient care, where one team of nurses and doctors is supposed to smoothly transition to another without harm. But studies have shown that continuity in care can be accomplished without Draconian treatment of residents and other lower-ranking medical staff.

I see in my practice the significant harms that patients can suffer while seeking medical care. The last thing modern medicine needs is to treat its rising stars as if they were terrorists, subject to so-called “harsh interrogation” tactics, including long, sleepless hours. Hospitals and senior staff are sending a horrible message to their young colleagues about caregiving, compassion, and concern, “just because this is the way they were trained” and “it’s the way it always has been.” Physicians, heal thy selves, and please, for your patients’ sake, stop abusing each other.

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