I wouldn’t trust my Uber driver to drive me after they’ve been awake for over 24 hours. Why would I trust my doctor?
Since starting medical school and hearing about the dreadful 24-hour shifts, I’ve constantly wondered why they are standard of practice, let alone legally allowed. Why would a hospital want the liability of a sleep-deprived doctor?
I first saw the effects of a 24-hour shift during my general surgery rotation. I worked with outstanding surgery residents who were thorough, compassionate, and attentive. One morning I greeted the senior on my team. He was at a computer. As time passes, I think to myself, is this guy really about to ignore me? I sat down at the computer next to him and realized that he was asleep. Sitting up. In the middle of placing an order. I felt a lot of empathy for him, as he was just another trainee in a broken medical education and hospital system. At the same time, I wondered, “How was he scrubbed into an open abdominal surgery an hour ago?”
Controversy surrounding extended shifts has existed since the start of medical education. In fact, the term “resident” originated from the fact that new physicians in training would live in the hospital many decades ago. Thankfully, we have stepped away from these times.
The Libby Zion case exemplifies the controversy over long work hours. She was an 18-year-old girl who passed away in a hospital in New York City The death was attributed to a preventable mistake committed by a sleep-deprived resident finishing a 36-hour shift. This led to a mandate in New York that residents were limited to an 80-hour work week with no more than 24 consecutive hours, which was extended to all residents in 2003.
In 2011, the ACGME mandated that interns be limited to 16-hour shifts, but second and third-year residents be limited to 24 hours. This was repealed in 2017, reverting to the previous practice of an 80-hour work week limited by 24-hour shifts.
The ACGME made these decisions based on the results of the iCOMPARE trial, which compared patient mortality and readmission rates between standard programs, which followed the 2011 guidelines of 24-hour limits, and flexible programs, which maintained 80-hour work week without limits on the length of shifts or mandatory time off between shifts. The results determined no difference between the two groups; however, it is crucial to understand the flexible programs were not required to use extended shifts, although they were permitted to. They found that for most rotations, the flexible programs chose to continue following the 2011 guidelines, limiting shifts to 16 hours, which speaks volumes in itself. This also means that it does not accurately compare the effects of extended-hour shifts to shorter shifts.
The ROSTERS study directly examined the effects shortened work hours (less than 16 hours) had on attentiveness, alertness, vigilance, and serious medical errors compared to extended work hours (more than 28 hours). This study concluded that residents on extended hours had significant attentional failures, which was associated with higher resident-related serious medical errors. Shortened work hours had a protective effect on the rate of serious medical errors.
Another study reported worsening symptoms of depression, anxiety, sleep quality, and migraines among residents working extended work hours. And another study concluded that extended shifts increased the likelihood of chronic sleep restriction. As you sit here and read these results, really think about it. Does this really surprise you?
It shouldn’t. Even the public agrees they wouldn’t want to be under the care of a doctor who has been awake for 24+ hours. I wholeheartedly agree, as well. Although any change regarding this topic is likely to occur prior to the start of my intern year, it is important to address the negative impacts this mandate has on the quality of life of interns and the effect it has on patient safety. Let’s move on to the era where residents are awake and alert while seeing and treating patients. I mean honestly, my shifts as a waitress were shorter.
Arlene Rivera is a medical student.
