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Maintaining Limit on Work Hours for First-Year Medical Residents Is Best for Patients

Health Letter, January 2017

By Rhoda Feng

It’s a familiar story: Medical residents go to work tired, care for patients for up to 28 hours straight while tired, come home tired and return to work the next day tired.

It is well documented that among medical residents, sleep deprivation due to excessively long work shifts increases residents’ risk of motor vehicle accidents, depression, and needle-stick and other injuries that can expose residents to bloodborne pathogens. Work-related fatigue can erode a doctor’s alertness and productivity, and jeopardize patient safety because sleepy residents commit more medical errors.

But many physician organizations see no problem with having medical residents work for up to 28 hours straight without sleep, and they are pushing for first-year residents to work such long hours.

Public Citizen is pushing back. And now, a yearslong struggle over medical resident work hours is coming to a head. A task force of the Accreditation Council for Graduate Medical Education (ACGME), the private organization that sets limits on medical resident work hours, on Nov. 4 issued a proposal that would allow first-year residents to work up to 28 consecutive hours.

“People don’t want sleep-deprived doctors at their bedside,” said Dr. Michael Carome, director of Public Citizen’s Health Research Group. “Medical residents are not superhuman and, when sleep-deprived, put themselves, their patients and others in harm’s way. This is not a partisan political issue, but one of public health and safety.”

Controversy over shift limits

In 2011, in response to a report issued by the Institute of Medicine and public pressure to revise its rules for shift hours, the ACGME capped shifts for first-year residents (also known as interns) at a maximum of 16 hours in a row, but allowed all other residents to work shifts of up to 28 straight hours without sleep.

But the 16-hour cap immediately encountered resistance from most residency program directors. Despite the ACGME’s conclusion that interns make more mistakes when working longer consecutive hours, many physician organizations continued to advocate lifting the 16-hour cap.

Why? One popular line of thinking is that shorter shifts lead to more transitions in care between doctors, which can contribute to medical errors. Opponents also argue that shorter shifts interfere with the training and education of residents. But transitions occur no matter the length of a resident’s shift; a resident handing off a patient after a 16-hour shift will be more alert than a sleep-deprived resident at the end of a 28-hour shift and more likely to provide accurate and complete information. And numerous studies in recent years have highlighted best practices that can be implemented during handoffs to minimize errors.

The past year saw renewed interested in this topic in anticipation of the ACGME’s scheduled five-year review of its 2011 work-hour limits. A Greek chorus of physician organizations averred that the ACGME should lift the current 16-hour shift cap for first-year medical residents and allow them to work 28 or more hours in a row without sleep.

Findings from a national survey

A national opinion poll commissioned by Public Citizen in September shows that the proposed 28-hour cap is at odds with the will of the American people, most of whom favor restricting the work shifts of medical residents to no more than 16 straight hours without sleep. Importantly, 86 percent of poll respondents were opposed to eliminating the 16-hour shift limit for first-year residents. Moreover, 80 percent of the public supported implementing the 16-hour cap for all residents, not just first-year residents. Most respondents also indicated that they would like to be informed if a medical resident treating them has been on duty more than 16 hours without sleep. The results were overwhelmingly bipartisan and consistent across all demographic groups.

“Sleep-deprived doctors must make life-or-death decisions while dealing with long overnight shifts,” said Arianna Huffington, author of “The Sleep Revolution.” “This latest poll shows that the American people want well-rested doctors treating them. When we take care of ourselves, we are more effective at taking care of others.”

Public Citizen also has ramped up its campaign to protect patients and medical residents from dangerously long resident shifts by:

  • Issuing a report (PDF), “Bipartisan Consensus: The Public Wants Well-Rested Medical Residents to Help Ensure Safe Patient Care,” detailing the poll results and summarizing research conducted to date on the dangers of sleep deprivation in residents to both the residents and their patients;
  • Sending a letter co-signed by the American Medical Student Association (AMSA), along with the report, to the ACGME, urging it to listen to the American public, reject any call to roll back the 16-hour work-shift limit for first-year residents and extend the 16-hour limit to all residents; and
  • Urging activists to email the ACGME and tell the accreditation group that they do not want their hospitals filled with sleep-deprived doctors. To date, more than 10,300 emails have been sent to ACGME president Dr. Thomas Nasca.

“The science is clear: Medical residents, like any other human beings, are unable to avoid the cognitive and motor limitations that inevitably accompany prolonged sleeplessness, and both residents and their patients are put at risk once residents’ shifts exceed the 16-hour mark,” said Dr. Sammy Almashat, a researcher with Public Citizen’s Health Research Group. “Sixteen-hour or shorter shifts are feasible and have already been implemented, for all residents, in some programs across the country. The ACGME flouted public opinion when it allowed second-year-and-above residents to work 28 hours consecutively without sleep in its 2011 rules, and it risks continuing to do so should it disregard the latest poll’s results.”

In the coming weeks, Public Citizen plans to continue pressuring the ACGME to reject its task force’s proposal and keep the 16-hour limit for medical residents in place to protect them and their patients from preventable harm. The ACGME is taking public comment on the proposal until Dec. 19 and will finalize its proposal in time for the 2017-2018 academic year.

Want to send a message to the ACGME? Go to http://pubc.it/2eVnMu3.