Posted by John Ager on 01 April 2013.
We have all heard of the grueling schedules young physicians are required to endure – 80 hour work weeks with 30 hour shifts of intense practice, applying what they have learned over many years. Just thinking about it is exhausting. It only makes sense that such hours are prone to produce sleepy, exhausted doctors who are going to be more likely to make mistakes than those that are well rested, right? Well, no so fast. Two studies, one by Johns Hopkins Hospital and the other by the University of Michigan Medical School, recently published in the Journal of the American Medical Association suggest otherwise.
In 2008, the Institute of Medicine, a non-profit public policy think tank, issued a report which made what seemed like a common sense suggestion that doctors in residency programs were putting patients at risk as a result of fatigue stemming from long work schedules. These observations were supported by well-researched studies. The Institute recommended capping shifts for residents at 16 hours. The recommendation was implemented in 2011 by the American Council for Graduate Medical Education, the accrediting body for post-graduate medical education. The new studies, however, indicate that medical errors by residents causing patient harm have increased 15-20 percent. While that may seem counterintuitive, it appears that there are some reasonable explanations. (Although I have not analyzed the methodology of any of the studies, and one year does not seem like a very long time upon which to base a comparison, the reported increase is so substantial it is hard to believe it is simply an anomaly.)
Handoff risks, those risks that arise when patient care is shifted from one health care provider to another, offer one explanation. The risk of patient harm increases with the greater number of handoffs that shorter shifts produce. Another is that hospitals do not appear to be adjusting staffing, so the same amount of work must be performed in less time. Haste makes waste. Finally, and perhaps most importantly, shift changes do not appear, at lease anecdotally, to increase the amount of sleep residents get, which was the primary reason for the recommendation for shift changes in the first place. If residents are getting no more sleep, the negative consequences of shorter shifts would seem to outweigh the potential benefits. Still, one has to wonder how much work is too much. At some point, long shifts must cause more problems than they solve. Is it at 25 hours? 35? 40? I am sure these recent studies will rekindle the debate about the wisdom of lengthy shifts which many see as a type of hazing, utilized only because “that’s the way it has always been done.”