Sleep deprivation: How Many Hours is Too Little For First-Year Doctors?
Much controversy has surrounded the medical community regarding the removal of hour restrictions for incoming first-year residents.
Sleep deprivation is an issue, although the change is not as dramatic as it sounds. In 2011, because of concern about the ability of incoming residents to adjust to overnight shifts and deal with sleep deprivation, the Accreditation Council for Graduate Medical Education (ACGME) started limiting incoming residents to 16-hour shifts with 8 hours in between shifts. Also, the maximum of time a resident could spend in the hospital was limited to 24 hours. Because a recent randomized clinical trial—the second highest level of evidence after meta-analysis— examining restricted versus non-restricted shifts showed no difference in outcomes, the ACGME decided to reinstate 28-hour shifts for first-year residents.
This about-face means that residents who weeks ago were medical students with no experience managing patients other than the training afforded by their medical school will face the same burden as seasoned residents: the onslaught of 28 hours of taking care of patients that they sometimes may not know well. They will face dangerous situations with dying patients and fewer resources available than during the day shifts. This change also puts larger burdens on senior residents who will have to very closely manage both patients and incoming residents adapting to their new roles.
PHOTO CREDIT: Our Chemist
This decision was open to public commentary for the customary period and faced much backlash from resident organizations looking out for the well-being of their members, but it also garnered support from residency directors and professional societies.
Residents complain rightly that the volume of patient management they are seeing is dissimilar to that of prior years due to an increase in the volume of patients, decreased resources, and increased administrative tasks. Residency directors argue that many of the residents who have gone through training after the hour cap was implemented are not competent enough to act as attending surgeons and physicians after they are done with residency. Both residents and residency directors agree that sometimes adhering to hour restrictions can affect patient care in critical moments when a new physician takes over care from the physician who initially saw the patient.
The contradiction of increased patient burdens experienced by residents alongside decreased skill managing patients post-residency stems from the fact that the administrative burden on all physicians has increased substantially from prior decades where little work was done on a computer and most of the work was done at the bedside.
For every one-hour of patient care done today in non-surgical settings, five hours are spent facing a computer screen. That time in front of a computer screen teaches little with regards to managing patients and understanding their disease processes. This fact is something many residency programs have not adjusted nor have these programs provided resources such as increasing nursing staff, increasing advanced level practitioners such as nurse practitioners or physician assistants.
Residency programs have failed to adjust to this fallout from imposing hour restrictions in the face of a changing field. Thus, residents are left to deal with administrative burdens such as different departments asking for clarification for billing purposes that need to be re-entered, putting in orders for medications patients are requesting or reconciling their long list of home medications, changing orders because pharmacists disagree with the syntax, discharging patients who have been hospitalized for months, writing notes daily, and other tasks necessary for patient care but time-consuming and time taken away from patient care.
Despite the hour restrictions, working over 80 hours weekly as a practicing surgeon or physician is still the norm.
Dr. Thomas Nasca, the ACGME’s Chief Executive Officer stated that the elimination of duty hours for first-year residents will allow first-year residents to grow faster, as extended hours require “residents [to] prepare in real patient-care settings for the situations they will encounter after graduation.” What Dr. Nasca alludes to is that patient care and the role of physicians extends beyond the duty hour restrictions.
In other words, many attending physicians provide 28-48 sequential hours of direct patient care with little rest in between, totaling over 100 hours weekly. To prepare for these challenges, physicians in training should be held to these same extended hours and their accompanying challenges, so that they can learn to adapt just as they are beginning residency. Managing patients at night under little supervision allows residents to develop autonomy and learn to deal with critical issues independently.
IN THE PHOTO: Doctors and medical personnel examine a patient in the trauma unit at Stroger Hospital, Chicago. PHOTO CREDIT: New York Times
Unfortunately, many older physicians believe that residents are not as resilient as in the past because they do not work the same 110 hours per week that older physicians had to work during their residencies.
This argument ignores the fact that morbidity and mortality in those times were lower than it is today because most patients died of their diseases before being seen in the hospital. Nowadays, there is a more multi-disciplinary approach to patient care, which has exponentially increased the number of treatment approaches and increased the complexity necessary to deliver optimal care to patients. Moreover, technology has enabled patients to live with a number of medical illnesses, which is the blessing and curse of technological advances in medicine.
Put simply, the array of things physicians-in-training do not know that can be done to improve patient outcomes today is broader than it used to be.
The decision to start restricting hours historically arises from the Bell Commission’s decision about duty hours, which arose as a result of the death of a young woman, Libby Zion. Her father who was a high profiled attorney and frequent writer for the New York Times, wanted justice and reform in the medical system to correct what may have led to his daughter’s death.
Libby Zion was a young girl who arrived at a New York State hospital with signs of sepsis. Sepsis is a systemic infection that can arise from multiple sources but is usually bacterial. However, the patient was thought to have a more benign viral illness, and moreover, she was put on medication that reacted in dangerous ways with other medication prescribed at the hospital.
Much blame was put on the medical residents being too sleep-deprived to realize the dangerous interactions between the medications and to identify a much worse infection that may have warranted intensive care as opposed to general medical care. The attending physician was also criticized for not coming in to see the patient or guiding his residents appropriately.
The Bell Commission was a group of lawyers, physicians, and politicians who set up a committee to investigate why this error happened and what can be done so that it never would happen again. The Bell Commission in their indictment reasoned that sleep deprivation and lack of supervision led to the fatal errors and that reform to limit hours to 80 hours per week and shifts to no more than 24 hours might have prevented this death.
It is important, however, to put this preventable death into context: over 400,000 deaths every year in America result from preventable medical errors. Behind cardiac disease (~610,000 deaths) and cancer (~595,000 deaths), medical errors may be the third leading cause of death nationwide and the least understood. Long hours and concomitant sleep deprivation may be just one of the modifiable risk factors that can lead to a reduction of preventable medical errors – even so, the true incidence of deaths from sleep deprivation is still poorly understood.
PHOTO CREDIT: British Medical Journal
There is strong evidence to support the idea that sleep deprivation is a major cause of morbidity and mortality among high-stress professions, especially fields like medicine.
Sleep loss of fewer than 30 hours reduced overall performance metrics by more than 1 standard deviation overall and 1.5 standard deviations in specifically clinical performance metrics in one meta-analysis of over 60 studies. Worse yet, many adults underestimate the effect of sleep deprivation and there is no evidence to support the notion that surgeons and physicians are immune to these effects. When testing simple acts of vigilance and mathematical calculations, chronic partial sleep deprivation of 5 hours of sleep for 7 days successively is equivalent to a short-term sleep loss of 24 sequential hours — both lead to dramatic decrease in performance in these tasks.
Another type of preventable error that may lead to increased complications and death stems from the concept of “the handoff” of patients to other providers. Given the work hour restriction, the theory is that transferring complex care to another provider leads to missed problems that might not be addressed by subsequent providers such as a prior history of a surgical procedure only the admitting team knows or a recent medication not listed in their actual medications.
As a result, the subsequent provider team that takes over may omit valuable information to further subsequent providers and teams, which may contribute to errors leading to morbidity or even mortality.
Hence, many experts opine that it is not the sleep-deprived residents, which cause most of the errors and lead to increased near misses and increased morbidity/mortality among patients in the hospital setting, but that the culprit is actually missed information in these handoffs of patient care. Handoffs are the integral transfer of patients to other providers who will follow the patient afterward, and the process of doing this handoff is called the sign-out.
There is evidence that potentially preventable adverse events are strongly associated with coverage of a physician who was not part of the primary team, resulting in a physician managing a patient with whom he or she is not familiar.
New evidence has emerged from a recent randomized clinical trial known as Flexibility In duty hour Requirements for Surgical Trainees (FIRST trial) that looked at the exact effects of restricting hours for surgical residents, as compared to eliminating the restriction.
The residents purported to have a better experience in the flexible hours’ group –the group which was allowed to work more than 80 hours per week 24 hours per day – with regards to managing critically ill patients and being able to see them through regardless of the hours worked.
The study also led to a surprising conclusion. It turned up one important but poorly recognized fact: the increased handoffs in the restricted hours’ group led to no more deaths or morbidity as many assumed they would.
The trial however did have some notable weaknesses: poor compliance of reported hours (such that it is possible that both trial groups worked the same amount of hours but one group underreported their hours); institutions that have additional resources to deal with complex patients as opposed to community hospitals; and little application in more cognitive fields like medicine, neurology, and psychiatry for instance as opposed to procedural fields like surgery, neurosurgery, and orthopedics.
This last concept is becoming more widely recognized as the volume of procedures done defines expertise in those procedures and in procedural fields like surgery. This is because the more you do of a given procedure, the better you get at it. However, this may not hold within the more cognitive fields in medicine such as psychiatry where having a clear linear thought process is critically important as opposed to more procedural fields where it may not be the case. However, there is very little research in this area. Most importantly, we do know that in both surgical and non-surgical specialties sleep deprivation is detrimental.
To conclude, the ACGME eliminating hour restrictions may not be that significant for patient care. As a result of this decision, first-year residents will work 24-hour shifts that may extend to 28 hours if necessary, just as more senior residents do.
Yet the message the ACGME is sending is concerning. It comes in the face of little research available to understand sleep deprivation among medical and surgical residents and of existing evidence that sleep deprivation is real, dangerous, and underappreciated especially in medicine.
Furthermore, the changes in hour restrictions do nothing to address the fact that our generation of physicians must contend with an increase in administrative tasks and time spent in front of a computer screen than other generations of physicians had.
In addition, the danger of sleep deprivation is real and the increasing number of preventable deaths in the hospital setting is startling and requires more research. This fact then serves as a backdrop to another startling reality: our physicians are not sufficiently trained to deal with the realities of delivering health care.
Moreover, the procedural fields where doing more procedures increases the physician’s effectiveness such as in surgery, orthopedics, neurosurgery, urology, etc. may well require from new residents additional hours to make up for their lack of experience. On the other hand, in the more cognitive fields of medicine, psychiatry, neurology, etc. the costs of residents working more hours may outweigh the benefits.
The ACGME has not come to terms with such nuances in residency training and uses an outdated “one size fits all” approach despite variations across specialties. The ACGME has also not fully taken into consideration the fact that the dangers residents face being overworked and sleep deprived arise largely from a number of administrative tasks they perform that are too time consuming.
Thus, the ACGME is not accounting for the realities of the work physicians face, and not taking on board individual differences as some are more adept at computers than performing complex surgeries or managing complex patient care in the dark hours of the night with little supervision. These realities are ones that the ACGME has to grapple with for the good of society and for the good of the residents who made the decision to take up their professions to do no harm, to themselves or their patients.