In recent years, there has been a significant increase in resident unionization across the country, driven largely by the grueling working conditions many residents face. While the most pressing issues are pay and burnout, one contributing cause is the long hours of training that contribute to resident sleep deprivation – a serious threat to resident health and patient safety. Despite duty hour restrictions imposed by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 and revised in 2011, which cap resident workweeks at 80 hours and shifts at 24 hours, marathon shifts continue to be a common practice.
These dedicated professionals stand on the front lines, navigating the complexities of patient care with commitment and skill. Yet, relentless schedules and sleepless nights take an undeniable toll on their cognitive abilities and decision-making. In the country with the largest health care system in the world, why are the doctors of the future being put in this situation, endangering patient lives as a result?
Numerous studies have shown the dire effects of sleep deprivation on resident safety, including depression, somatic complaints, and pregnancy complications. However, the most severe danger to resident lives due to sleep loss is the increased incidence of motor vehicle accidents; car accident rates have been found to be higher among residents, especially post-call.
The issue of resident sleep deprivation extends beyond individual well-being—it poses a tremendous threat to public health. Studies have consistently shown the link between resident sleeplessness and medical errors. Residents frequently work 24-hour shifts, and the impact of 24 hours without sleep has been found to be equivalent to a blood alcohol content of 0.1% (the legal limit to drive is 0.08%). A New England Journal of Medicine study found that interns working 24+-hour shifts made 36% more serious clinical errors compared to those working 16-hour shifts. The more sleep-deprived group also made 21% more serious medication errors and almost six times as many diagnostic errors than their less sleep-deprived counterparts.
The rigorous schedules imposed on residents jeopardize their capacity for sound judgment, increasing the risk of medical mistakes. Residents themselves are able to recognize this impact on their cognition, as demonstrated by a Journal of the American Medical Association study. When surveyed on the most serious medical errors they had committed, 41% of residents reported that the cause of their mistake was fatigue; 31% of these fatigue-caused errors resulted in patient death.
Furthermore, resident sleep deprivation is associated with burnout, a current epidemic among health care professionals. A University of Pennsylvania study that surveyed interns at the start and end of intern year found that the prevalence of “high” sleep deprivation increased from 9% to 43% over the year; similarly, prevalence of burnout jumped from 4% to 55%.
Burnout not only diminishes the quality of care provided but also erodes physician compassion and empathy, which are essential for the healing process. Elevated levels of depression, anxiety, confusion, and anger frequently accompany fatigue, and this has been found to result in emotional detachment and a diminished capacity for compassion towards patients. In the aforementioned study, the prevalence of elevated depersonalization scores jumped from 13% to 68% over the year, and the prevalence of elevated emotional exhaustion scores jumped from 9% to 68%. Furthermore, suicide, a severe consequence of burnout, was found to be the second leading cause of resident death. A Yale study found that suicidal ideation increased by 370% over the first three months of residency.
Importantly, since 2003, the ACGME has imposed an 80-hour cap on resident workweeks (averaged over four weeks), with a 24-hour cap on each shift. However, many residents may under-report hours worked due to fear of retribution or punishment from their program or superiors. Others may not report duty-hour violations due to the risk of their own program losing accreditation as a result. One significant deterrent is that residents who report work-hours violations are not provided with whistleblower protections that protect their employment.
To combat the epidemic of resident fatigue, several steps must be taken. The duty-hours cap must be enforced, and residents should receive whistleblower protections. The culture within medicine needs to change – there is often a pressure to conform, overwork, impress, and hide mental health struggles. Another way to decrease the workload on individual residents is to increase residency spots. Bills such as the Resident Physician Shortage Reduction Act have been introduced in Congress with this goal. Currently, residents lack bargaining power and cannot change programs – they have no alternative but to remain in their program and accept the conditions of employment, even if they are unsatisfactory. Competitive pressures must be placed on hospitals to improve resident working conditions.
Physicians counsel patients on the importance of health and well-being, yet the current system demands that they work under conditions that undermine their own health. Resident sleeplessness looms large as a public health emergency, with severe consequences including resident suicide, car accidents, and obstetric emergencies. We must call upon lawmakers and the ACGME to act now to ensure no more lives are lost due to the dangers of resident fatigue.
Medha Venigalla is a medical student.
