Medical residents shouldn’t be working 28-hour shifts

Jason Fodeman Physician
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New guidelines governing how long medical residents can be on duty were implemented this summer, but rather than solving a problem, these parameters jeopardize patient safety at our nation’s teaching hospitals. They do little more than pay lip service to curbing long shifts and fail to protect patients from fatigued, overworked residents.

The issue of how many hours medical residents can work in a shift has always been a contentious one. There is a fine line between education and exploitation, with significant ramifications on quality of care.

The old guidelines were implemented by the Accreditation Council on Graduate Medical Education (ACGME) in 2003. These guidelines restricted the work week for medical residents to 80 hours with four days off per month and limited shifts of up to 30 straight hours.

In late 2008, the Institute of Medicine (IOM) concluded these duty hours created resident fatigue, which fostered an unsafe working environment that contributed to medical errors and accidents. It found “considerable scientific evidence that 30 hours of continuous time awake, as is permitted and common in current resident work schedules, can result in fatigue, and that adjustments to the 2003 rules are needed.”

To ensure adequate patient safety, the IOM recommended decreasing the maximum shift to either 16 straight hours or keeping 30-hour shifts but installing a protected five-hour break. It was speculated that the ACGME would adopt the IOM’s recommendations. Unfortunately, it did not.

According to the newly approved ACGME guidelines, residents in their first year of training can work 16 straight hours while more senior residents can still work 28 straight hours. Thus for most medical residents, the ACGME’s solution will reduce maximum shift lengths from 30 to 28 straight hours. This is still very dangerous for patients.

Residents make life and death decisions, often in the middle of the night. The work is constant, and the possibilities for mistakes are almost limitless. A misplaced decimal point in a prescription order can make all the difference.

And it is important to remember whom the decisions of these young doctors affect. Residents are caring for real people — someone’s parent, someone’s son, someone’s friend, someone who will leave a lot of people devastated if things go wrong. It is imperative that residents are alert and able to think clearly and intervene appropriately. As the IOM concluded, during these long shifts residents are simply too tired to maintain peak performance, and, as a consequence, patient care suffers.

The ACGME does concede that “strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m. and 8:00 a.m., is strongly suggested.” While this is a nice overture by the ACGME, residents who can barely stand on two feet in the early morning hours do not need to be told to sleep when they can. The reality is that, for the most part, the work is so plentiful and the resources so scarce that even on a 30-hour shift, opportunities to put one’s head down even for a few minutes are few and far between. Thus, without explicitly guaranteeing naps as the IOM recommended or enacting measures to decrease the work load or increase staff to make it a real possibility, the suggestion isn’t worth the paper it’s printed on.

Furthermore, the discrepancy in duty hours for residents in different years of training makes little sense and demonstrates at best a flawed thought process. By reducing the duty-hour limits for first-year residents to 16 hours, the ACGME is tacitly acknowledging that working between the 16th and 28th hour is unsafe. Yet, the group is compelling more senior residents to do just that.

The ACGME defends its proposed two-tiered regulation system, arguing that these “new standards address differences in capabilities and practices for first-year residents, placing more restrictive limits on their hours and requiring added supervision.”

Junior residents may indeed have less knowledge and clinical experience than their superiors, but one’s ability to function for prolonged periods of time on little or no sleep shouldn’t change with rank. Sleep is a necessity, not a luxury that more “capable” workers learn to do without.

If anything, one would think that the ACGME should have decreed that senior residents work fewer continuous hours than their junior colleagues. After all, they have more responsibility when it comes to clinical decision-making and have fewer people looking over their shoulders. When a first-year resident makes a mistake, there is a chance that the second- or third-year resident on call might catch it. A senior resident often lacks this luxury. If an intern is tired and slowing down, the senior resident who is ultimately responsible must pick up the slack. The senior resident on call does not have this out either.

The long-awaited duty-hour recommendations from the ACGME were not worth the wait. The ACGME has decided the 30-hour shifts that medical residents work are unsafe, but 28-hour shifts are acceptable. Does this pass the common-sense test?

The ACGME clearly felt pressure and backlash from the IOM’s critical report. The ACGME decided not to definitively address the IOM’s concern. Instead, it has adopted token reforms, clearly trying to create the illusion of improvement and hoping that no one is paying attention to the specifics. This approach may indeed score the ACGME some positive headlines and be a political winner. Unfortunately, it takes more than favorable headlines to protect patients and combat medical errors.

Jason D. Fodeman, M.D. is an Internal Medicine Resident.