TUESDAY, Sept. 3, 2002 (HealthDayNews) -- The long hours of doctors-in-training take their toll in the form of duller minds and fumbling fingers and may be harming patients, a new study has found.
Residents, who typically work more than 24 hours without sleep, are cheap labor for hospitals. This heavy workload, which has long been controversial, recently has taken on new urgency.
Congress is now debating two bills that would shorten residents' work weeks to 80 hours. And earlier this summer, the Accreditation Council for Graduate Medical Education, which sets standards for the nation's 1,100-odd residency programs, issued mandatory guidelines, effective July 2003, that establish an 80-hour work week.
The guidelines, which until next summer are voluntary, also limit continuous shifts to 24 hours (plus up to six hours for extras like education and transfer of patients), and impose a minimum 10-hour rest period between shifts. Failure to comply with the rules could result in a program's loss of accreditation -- and millions of dollars in Medicare payments.
"You would never think of letting a pilot fly for 24 hours straight," said Dr. Sigrid Veasey, a sleep researcher at the University of Pennsylvania School of Medicine and leader of the new study. But young doctors, who are equally entrusted with the lives of others, do so as a matter of course.
Veasey and her colleagues reviewed 50 previous studies of fatigue and residents, and their findings appear in tomorrow's Journal of the American Medical Association.
They found that sleep deprivation affects both a doctor's cognitive ability -- the skill needed to read a heart monitor correctly, for example -- and surgical precision.
One study found that complication rates were 45 percent higher for surgical residents who'd been "on call" the night before. Two others of simulated laparoscopy found that residents performed worse and needed more time to operate on post-call mornings.
"One of the consistent findings in the careful studies is that subjectively, there's a gross under-appreciation of how impaired you are when you're sleep-deprived," Veasey said. "That goes for both chronic loss of sleep and staying up all night. When you give [a tired resident] the task, they can't do it."
How much, if at all, sleep deprivation among residents contributes to the estimated 44,000 to 98,000 deadly hospital errors each year in this country isn't known, the researchers said. However, the U.S. government's Agency for Healthcare Research and Quality is now funding $300 million worth of studies to address the issue of medical errors, including the role of residents' restfulness and scheduling.
The effects of little rest on the doctors themselves are clearer. Residents face a sharply higher rate of deadly car accidents during their training, especially in the hours when they are no longer on call. "We lose a medical student every two to three years at Penn," Veasey said.
Makeba Williams, legal affairs director for the American Medical Student Association, which supports the 80-hour work week, said some evidence suggests that going more than 24 hours without sleep has the same effect on cognitive function as a blood alcohol content of 0.1, which is above the legal limit in most states.
Williams, who is between her third and fourth years of medical school, said residents also have about three times the rate of depression as the general population, which may be due to their lack of sleep.
Ingrid Philibert, who oversaw the accreditation group's guideline debate, said the 80-hour requirement was drawn from standards for internal medicine residents and New York State's maximum work week, and it's also the figure used in several studies of fatigue.
But Philibert said 80 hours isn't a magic number above which all residents will perform badly. "There are huge interpersonal differences in how people respond to sleep deprivation," she said.
What's more, unpublished data from Europe suggest that the number of patient handoffs from doctor to doctor, not the length of shifts, may generate physician errors. "A tired physician familiar with the case will perform better than a rested physician who doesn't know the details," Philibert said.
Still, the latest study suggests that simply shortening the work week -- to a level twice that of the typical employee -- isn't necessarily a solution to the problem of exhausted residents.
A better approach, Veasey said, would be to shape schedules using scientifically sound principles based on circadian rhythms. That would include two-hour naps timed for the periods of the day when the body most needs rest, and patient rounds at 10 a.m. rather than 8 a.m., when residents are most groggy.
These steps and related measures would help ease the strain on residents while sparing hospitals crushing costs from having to boost staffing levels, she said.
What To Do
For more on patient safety, try the Agency for Healthcare Research and Quality or the Medical College of Wisconsin.
