Just read an interesting article in this week's edition of the New England Journal of Medicine "The ACGME's Final Duty-Hour Standards--Special PGY-1 Limits and Strategic Napping" by J Iglehart. This article brings up an issue that I believe affects quality of patient care and the mental health of physicians in the United States: severe sleep-deprivation while on duty. I don't know if you are all aware, but since 2003 physician residents are now only "allowed" to work 80-hours a week. I say "allowed" because resident physicians literally resided in hospitals in the past when they typically worked 120-hours a week. I don't even know how past physicians completed their training because working 80-hours a week (averaged over 4 weeks) year-after-year is difficult, stressfull, and definitely affects one's mental and physical health. Usually residents are on call every four nights. While call duties vary per specialty, as a surgery resident I was typically on call for 24 to 30 hours at a time. During that time period, I was operating, completing invasive bed-side procedures, seeing consults, and managing patients in the ICU or wards. I was so busy that I was grateful to even get an hour of uninterrupted sleep per call.
Research has shown that sleep-deprived and over-worked resident physicians are at an increased risk of being involved in motor vehicle accidents, getting more needle-stick/laceration injuries, developing depression, and giving birth to growth-retarded or premature babies. From my experience in residency, I can think of several post-call residents getting in minor car accidents on their way home and have, myself, struggled to stay awake at the wheel post-call.
This NEJM article describes slightly revised duty-hour standards released by the Accreditation Council for Graduate Medical Education (ACGME) last month. If residency programs do not adhere to these standards, then they are at risk of losing accreditation (which has temporarily happened to some big name programs) and losing Medicare suppport of $100,000 per resident. While reading this article I was expecting some major revision to the duty hour standards. However, the only revision I found was that now interns (PGY-1 residents) cannot exceed 16 hours per call shift without. More senior residents are allowed to be on call for 24 hours, plus an additional 4 hours for handing off patients or completing care (this really translates into maximum of 28 hour calls). Not suprisingly, the American College of Surgeons "expressed 'very grave concerns' regarding the PGY-1 limits, predicting 'a negative impact on patient safety and continuity of care unless there is a substantial increase in human resources to replace the residents.'" I also predict that by allowing only interns to go home early while on call, the more senior residents are going to be even more over-worked trying to cover for them. Several advocacy groups, including Public Citizen, have been try to petition OSHA to take over duty hour regulation and to limit continuous call duties to 16-hours for all residents.
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3 comments:
Thanks for this post, Brynnen. I agree that the status quo is a bit frightening. The Greyhound bus trip from San Francisco to El Paso, TX is about 28 hours. Imagine settling into your seat as the bus driver announces he will be taking you the entire way.
I agree that hours should definitely be shortened and I like that you put allowed in quotes=) What I found striking about this was the tie to Medicare and potentially losing $100K per resident for noncompliace. I wonder if this will be more of an impetus to follow better occupational health standards than the well being, performance and patient safety that fewer hours provides.
I agree with limiting resident work hours AND enforcing those limits (which is another problem altogether). However to play devil's advocate, it has also been shown that the most dangerous time for a patient is the trade-off between providers and with less work-hours there are more trade-offs. Thus to make sure we don't trade one evil for another, we need to devise a safer, more comprehensive way to transfer care between providers when people end their shifts.
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