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More Information on Medical Resident Work Hours

Petition to Reduce Medical Resident Work Hours

September 2, 2010

PART 4: THE SAME RULES TO PROTECT RESIDENT PHYSICIANS AND SUBSPECIALTY RESIDENT PHYSICIANS WILL ALSO PROTECT PATIENTS

More than just harming resident physicians, long work hours have been shown to have negative effects on patients by increasing chances for accidents and errors in the delivery of medical care. A significant body of literature supports the common-sense notion that it is unsafe to subject patients to sleep-deprived and exhausted physicians-in-training.

In a randomized controlled trial, interns were found to make 35.9% more serious medical errors while working a traditional schedule with 24+ hour shifts occurring every third night, as compared with a schedule that limited their shifts of 16 consecutive hours (p < 0.001).[1] In a separate nationwide cohort study of injuries to patients caused by medical management (adverse events), researchers found that interns working five or more 24+ hour shifts in a month reported 7.5 times as many fatigue-related errors that injured a patient, and four times as many fatigue-related errors that led to a patient’s death than did those who did not work 24+ hour shifts.[2] Altogether, one in five interns reported making a fatigue-related error that injured a patient, and one in 20 reported making a fatal error due to fatigue. These data suggest that thousands of patients may die each year in the U.S. due to resident physicians’ extreme work schedules.

Other studies have shown that well-rested resident physicians outperform their sleep-deprived peers on a wide range of tasks, including basic rote memory, language, and numeric skills;[3] retention of information and problem-solving skills;[4] tests of visual attention, short-term memory, and coding ability;[5] and tests of concentration.[6] The procedural skills of resident physicians have also been shown to suffer under conditions of sleep deprivation or restriction, with decreases in resident physicians’ performance of electrocardiogram interpretation,[7] anesthesia monitoring,[8] intubation of mannequins,[9] and simulated laparascopic cholecystectomy.[10] A paper published in the journal Nature found that staying awake for 24 hours impairs cognitive psychomotor performance to the same degree as having a 0.1% blood alcohol level, a value above many U.S. legal driving limits (0.04 g. %-0.08 g. %).[11]

One of the strongest arguments for reducing resident physician work hours is an ethical one: overwork interferes with the development of professional values and attitudes that are an essential part of being a physician.[12] Fatigue can cultivate anger, resentment, and bitterness — often directed at the patient — rather than kindness, compassion, or empathy. As was evident from many of the studies on negative mood and its relationship to long work hours, this attitude is promoted when meeting a patient’s needs becomes incompatible with meeting a resident physician’s own needs. The following entry from a resident physician’s diary illustrates the types of feelings engendered by typical resident physician work schedules:

1AM and I’m ready to go to bed: one should never be ready to go to bed in the ICU [Intensive Care Unit] — you’ll always be disappointed. Anyway, I’m on my way to the EW [Emergency Ward] … when there’s a code [cardiac arrest]. Get up there and find [a resident physician] trying to intubate a lifetime asthmatic who is as blue as this ink. I keep thinking — he’s blue enough to go to the ICU. I keep hoping he’s going to be too blue to go anywhere. Probably a nice man with a loving wife and concerned children, but I don’t want that SOB to make it because I’ve got one special who is going to keep me up 2 more hours. I don’t need an intubated, blue, pneumothoraxed SOB coming to my unit… I don’t want the asthmatic SOB to live if it means I don’t sleep. I don’t want the special to live if it means I don’t sleep. I just want sleep.[13]

Although patient protection is not the principal focus of this petition, it is clear that in protecting resident physicians from long work hours, OSHA would also be protecting patients.

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[1] Lockley SW, Cronin JW, Evans EE, Cade BE, Lee CJ, Landrigan CP, Rothschild JM,Katz JT, Lilly CM, Stone PH, Aeschbach D, Czeisler CA; Harvard Work Hours, Health and Safety Group. Effect of reducing interns' weekly work hours on sleep and attentional failures. N Engl J Med. 2004 Oct 28;351(18):1829-37.

[2] Szklo-Coxe M. Are residents' extended shifts associated with adverse events? PLoS Med. 2006 Dec;3(12):e497.

[3] Hawkins MR, Vichick DA, Silsby HD, Kruzich DJ, Butler R. Sleep and nutritional deprivation and performance of house officers. Journal of Medical Education 1985;60:530-5.

[4] Hart RP, Buchsbaum DG, Wade JB, Hamer RM, Kwentus JA. Effect of sleep deprivation on first-year residents’ response times, memory, and mood. Journal of Medical Education 1987;62:940-2.

[5] Rubin R, Orris P, Lau SL, Hryhorczuk DO, Furner S, Letz R. Neurobehavioral effects of the on-call experience in housestaff physicians. Journal of Occupational Medicine 1991;33:13-8.

[6] Robbins J, Gottlieb F. Sleep deprivation and cognitive testing in internal medicine house staff. Western Journal of Medicine 1990;152:82-6.

[7] Friedman RC, Bigger JT, Kornfeld DS. The intern and sleep loss. New England Journal of Medicine 1971;285:201-3.

[8] Denisco RA, Drummond JN, Gravenstein JS. The effect of fatigue on the performance of a simulated anesthetic monitoring task. Journal of Clinical Monitoring 1987;3:22-4.

[9] Smith-Coggins R, Rosekind MR, Buccino KR. Rotating shiftwork schedules: can we enhance physician adaptation to night shifts? Academic Emergency Medicine 1997;4:951-961.

[10] Taffinder NJ, McManus IC, Russell RCG, Darzi A. Effect of sleep deprivation on surgeons’ dexterity on laparoscopy simulator. The Lancet 1998;352:1191.

[11] Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997;388:235.

[12] Green MJ. What (if anything) is wrong with residency overwork? Annals of Internal Medicine 1995;123(7):512-7.

[13] Groopman LC. Medical internship as moral education: an essay on the system of training physicians. Culture, Medicine, and Psychiatry 1987;11(2):207-27.

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