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Should Medical Residents Be Required to Work Shorter Shifts?

Discussion in 'Doctors Cafe' started by Egyptian Doctor, Mar 21, 2013.

  1. Egyptian Doctor

    Egyptian Doctor Moderator Verified Doctor

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    Being a medical resident has long been a trial by fire. Current rules allow most residents to routinely work 28-hour hospital shifts, just not on consecutive days.


    Critics of the system point to research, and sometimes common sense, that suggest fatigue causes mistakes and can put both patient and doctor at risk. Current shift limits recommended by the accrediting organization reflect that group's efforts to balance resident and patient safety with a strong environment for learning.


    Others in the medical community, including established doctors, feel the long hours prepare residents for what it's really like to be a physician. Some say patients are better served by doctors who stay with the patient longer, and worry residents are seeing fewer cases due to shorter shifts, and so entering their profession less well-trained.


    The harmful impact of fatigue is all too clear, writes Steven W. Lockley, Ph.D., a neuroscientist in the Division of Sleep, Brigham and Women's Hospital, Boston, and an associate professor at Harvard Medical School.


    Arguing that young doctors and patients are better served by allowing longer shifts is Jane Orient, a physician herself, and executive director of the Association of American Physicians & Surgeons.


    Many studies have shown the harmful effects on patient care when physicians become fatigued from the kinds of grueling shifts that are routinely required for doctors in training.


    Responding to those studies, the group that certifies graduate medical education programs most recently limited the shifts first-year residents can work to 16 continuous hours.


    That's a small step in the right direction but doesn't go far enough. When hours are reduced, medical error rates fall enormously. No other simple solution comes as close as a way of cutting errors.


    Even with the new limits, most medical trainees continue to work marathon shifts. The rules set by the Accreditation Council for Graduate Medical Education, or ACGME, allow most residents to work 28 hours in a row every other shift and 24 days in a row if they then have four days off. Although 80 hours is the official weekly work-hour "limit"—with a possible extra eight hours for education—this calculation can be averaged over four weeks, permitting much higher hours for several weeks each month. First-year residents, while limited to 16-hour shifts, have the same 88-hour workweek limits.


    While those are the limits on paper, it is uncertain how many hours a week residents actually work, in part because the hours are reported to the ACGME, the same body that accredits programs, creating a potential disincentive for accurate reporting. A study by our research team, the Harvard Work Hours Health and Safety Group, found 85% of residency programs in 2003-04 were noncompliant with the work-hour rules; an ACGME survey over the same period reported only 5% noncompliance.


    At Brigham and Women's Hospital, we quantified the effects of work hours on medical error rates in a group of first-year residents who worked in intensive-care units under two sets of conditions: a traditional schedule with 24- to 30-hour shifts every other shift, and a schedule with 16-hour limits. On the former schedule, the residents made 36% more serious medical errors than on the latter, and inadvertently fell asleep on duty twice as often on duty overnight.


    Longer shifts affect not just the safety and health of patients but that of physicians as well. In surveys conducted by our group, residents working 24 or more hours in a row reported sticking themselves with needles 60% more often, and had more than double the odds of having a car crash on the drive home from work as compared with shorter shifts. In a 2010 review of 23 studies on the effects of reducing resident work hours, all but one showed an improvement or no change in patient care or resident sleep or quality of life. There were no objective data showing that shorter work hours were worse for patients or physicians.


    Despite the increasing emphasis on evidence-based decision making in medicine, these data have often been met with a negative response.


    Those who oppose stricter work-hour limits say continuity of care demands long shifts. But even with 30-hour shifts, care of a patient eventually has to be handed over to another team. Medicine is also increasingly filled with specialists, a development requiring a team approach to deliver the best care. So we need to find better ways for teams to communicate and to transfer information, rather than insist that doctors risk their own and their patients' health by working beyond their biological limits.


    Others question the professionalism of doctors trained under shorter shifts. Today doctors realize that being "resident" in the hospital is not an efficient way to learn. Earlier specialization would be one solution, allowing individuals to spend less time in general training and more in their specialty.


    Doctors are not immune to biology. While we appreciate their dedication and sacrifice, we cannot allow them to harm others or themselves with the outdated and unnecessary "rite of passage" of 24-hour shifts.


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