Health Letter, April 2017
By Michael Carome, M.D.
If you’re not outraged,
you’re not paying attention!
Read what Public Citizen has to say about the biggest blunders and outrageous offenses in the world of public health, published monthly in Health Letter.
Like food, water and shelter, adequate sleep is vital for survival. We all need sufficient sleep to maintain our physical and mental health and well- being, as well as our capacity to do even simple tasks safely. Sleep also plays a crucial role in brain development, learning and memory formation.
A few years ago, the National Sleep Foundation (NSF) convened a panel of experts in sleep, physiology, internal medicine, neurology and psychiatry, among other specialties, to conduct a thorough review of all relevant medical research and to develop age-specific recommendations for appropriate sleep duration based on the most rigorous scientific evidence available. The panel’s recommendations, which were issued by the NSF in 2015, advised that healthy adults aged 18 to 64 should sleep seven to nine hours per day and that older healthy adults should sleep seven to eight hours per day to preserve their health and well-being.
But the Accreditation Council for Graduate Medical Education (ACGME) — along with much of organized medicine in the U.S. — appears to believe that medical residents are superhuman and therefore impervious to the adverse effects of short- and long-term sleep deprivation. How else can one explain the ACGME’s decision, announced on March 10, 2017, to rescind the current 16-hour shift limit on first-year medical residents (also known as interns) and allow them to work 28-hour or longer shifts without sleep — the same duration as residents in later years of training currently are permitted to work?
It is preposterous to think that medical residents at any level of training can remain healthy and perform well in the complex hospital setting while working shifts of 28 hours or more as often as every third night during residency training, which lasts three to seven years.
In fact, there is a mountain of scientific evidence demonstrating that residents forced to stay awake for more than 16 consecutive hours are at an increased risk of needlestick and other injuries, motor vehicle accidents and depression. Moreover, the most rigorously designed research to date revealed that first-year resident physicians working shifts of 24 or more consecutive hours made 36 percent more serious medical errors than those working shifts of no more than 16 hours.
The serious health risks of long work shifts for medical residents and their patients were highlighted by the prestigious Institute of Medicine — now the National Academy of Medicine — in a 2009 report and were among the reasons for the ACGME’s 2011 decision to institute the current 16-hour limit on work shifts for first-year medical residents. Indeed, in justifying this decision, the ACGME observed the following:
[First-year] residents may not have sufficient experience and skills to provide high-quality, safe patient care, while research indicates that under the current standards, this group works the longest hours of any cohort of residents … In addition, [first-year] residents make more errors when working longer consecutive hours. Entrusting care to residents with inadequate experience is neither good education nor quality, safe patient care.
Since 2011, there have been no new studies that refute the overwhelming evidence on the hazards medical residents and their patients face when residents work shifts of 28 or more hours without sleep.
The American public has more common sense than the ACGME when it comes to recognizing the dangers posed by sleep-deprived resident physicians. A national poll conducted in July 2016 showed that 86 percent of the public was opposed to lifting the 16-hour cap for first-year residents. Moreover, 80 percent of the public supported implementing the 16-hour cap for all residents, not just first-year residents.
In its March announcement, the ACGME disingenuously paid lip service to the importance of fostering the well-being of medical residents, ignoring the fact that repetitive sleep deprivation is incompatible with anyone’s well-being. Also, regarding the elimination of the 16-hour cap on first-year resident work hours, which will take effect July 1, 2017, the organization misleadingly claimed that “24 hours is a ceiling, not a floor.” However, under the new ACGME rules, there will not be a 24-hour ceiling on first-year resident work shifts. After 24 hours of continuous clinical care duties, first-year residents (like all other residents) can be required to work an additional four hours on activities related to transitioning patient care and participating in educational activities such as conferences. And after 28 hours without sleep, all residents, on their own initiative, can continue working: The current requirement to justify such circumstances in writing will be eliminated.
The ACGME’s action represents a dangerous step backward for the health and safety of resident physicians and their patients. This reckless move once again makes clear that the responsibility for protecting residents from unsafe work shifts must be removed from this unaccountable private organization and handed over, as all other worker safety issues are, to the U.S. Occupational Safety and Health Administration.