Critical Care

Regulating safe work hours for medical residents

In September, the Accreditation Council for Graduate Medical Education’s board of directors approved new standards that reduce the shift limit for first-year residents to 16 hours from 24 hours and encourage “strategic napping.” But some groups argue the rules do not go far enough to protect doctors-in-training from the hazards of sleep deprivation and fatigue.

“Late at night, when you’re that tired, there’s a tension between taking care of yourself and taking care of your patient,” said Dr. Charles Preston, a preventive medicine resident at Johns Hopkins School of Public Health in Baltimore and researcher with Public Citizen’s Health Research Group. Washington-based advocacy group Public Citizen and other organizations are calling on OSHA to further restrict medical resident work hours. OSHA has agreed to review their petition.

“We are very concerned about medical residents working extremely long hours,” agency administrator David Michaels said in a statement, “and we know of evidence linking sleep deprivation with an increased risk of needlesticks, puncture wounds, lacerations, medical errors and motor vehicle accidents.”

Indeed, research from the Harvard Work Hours Health and Safety Group in Boston shows first-year residents – also called interns – who work shifts longer than 24 hours are more than twice as likely as interns on shorter shifts to be involved in a motor vehicle crash leaving the hospital and 5 times more likely to have a near miss on the road. Preston recalled falling asleep midsentence during his clinical residency and said stepping away from patients to rest is “just not acceptable.” He continued, “If you’ve got work to do, or nurses are calling you, or patients are in danger because they’re about to crash, you’ve got to be there.”

The Accreditation Council for Graduate Medical Education, based in Chicago, oversees residency programs for 111,000 doctors-in-training. The new rules maintain the current weekly duty hour limit of 80 hours, averaged over four weeks, but set stronger requirements for fatigue mitigation, patient care and intern supervision. The rules, based partly on 2008 recommendations from the Institute of Medicine in Washington, are scheduled to take effect July 2011.

Dr. Thomas Nasca, CEO of ACGME and vice chair of the task force that developed the standards, said organizations calling for more restrictions are not considering the ramifications for patient safety in the future. “Physicians need to be trained to provide excellence in care and recognize their limitations with regards to fatigue and learn how to manage it,” he said. “And it’s best to learn that under supervision – where there’s a safety net that assures both your safety and the safety of your patient, rather than learning that by the seat of your pants when you enter independent clinical practice.” Nasca cited research published this year in the Journal of the American Medical Association (Vol. 303, No. 8) that indicated resident work hours have decreased dramatically since ACGME set the 80-hour limit in 2003. Most residents do not hit the maximum, and those who do are in specialties that will require them to work similar hours as practicing physicians, Nasca said.

Preston questioned why the 16-hour cap applies only to first-year residents while other residents are permitted to work 24-hour shifts. “There’s no reason to think that a second-year resident would be able to handle the chronic sleep deprivation that you get with residents better than an intern,” he said. Nasca countered that the first year should prepare residents to take on 24-hour care.

Neglecting their own health?

Recent research has raised concerns about medical students and residents overlooking their own safety and health. In a study published in JAMA in September (Vol. 304, No. 11), 14.3 percent of medical students reported experiencing moderate to severe depression, compared with 10-12 percent of the general population. And regarding mental illness, more than half of students with high levels of depressive symptoms believed revealing their illness would be risky to their careers. That same issue of JAMA included a research letter on “presenteeism” – showing up to work when ill – among resident physicians. A survey of more than 500 residents from a dozen hospitals found almost 58 percent came to work sick at least once in the previous year. About 31 percent of respondents reported working while sick more than once. Half said they did not have time to see a doctor about their illness. 

Study co-author Dr. Anupam B. Jena is a second-year resident at Massachusetts General Hospital in Boston. Jena recalled that he once continued working after coming down with food poisoning symptoms during an overnight shift, rather than calling someone else to fill in on short notice. (He stressed that he did not believe he was contagious.) Regarding fatigue, Jena acknowledged the challenge of balancing learning, patient care and resident wellness. “You are always tired, but you make sure that on the days where you’re not staying there 24 hours, you rest properly,” he said. “It becomes manageable in the short term. It’s not something you could do your whole life, but it is something that many people do for a couple years of their life.” In Preston’s view, the presenteeism research is “another example of the culture that is being fostered where you come in at any cost to yourself.”

But Nasca noted many resident programs use a program called SAFER – Sleep Alertness and Fatigue Education in Residency – to teach residents about fatigue. ACGME’s new standards also increase expectations for faculty to display correct behavior. Unfortunately, Nasca added, people get sick day and night. “So we walk this balance of working more than most others do in order to provide that level of care to our patients,” he said, “and part of residency education is learning how to do that.”