Coping with Shiftwork

Desperately Seeking Snoozin'
 

There’s an old saying that says, “If you get sick, don’t go to the doctor.  And if you end up going to a doctor, don’t let him (or her) put you in the hospital!”

Even though that can be construed as amusing or simplistic, there’s an element of truth in this adage.  Physicians, and particularly, physicians in training are some of the most sleep-deprived shiftworkers you will ever find.

According to a recent article from the Journal of the American Medical Association, most physicians-in-training in US hospitals are required to work 80 hours or more per week and often pull shifts of 30 consecutive hours.  Some also work more than 130 hours per week and are on call every other night.

From what we already know about shift work and sleep deprivation, this is definitely not a good thing for you and me.  According to David Dinges, PhD, fatigue prompts a wide-ranging series of unacceptable deficits.  He explains that as lapses of attention increase, alertness and vigilance becomes unstable.  Cognitive slowing occurs and time pressures increase errors while working memory declines.  A physician may respond to a medical emergency, yet fail to recall critical information relevant to patient care, or enter it into a chart.

The Institute of Medicine estimates that medical errors cause more than one million injuries to patients in US hospitals each year, and may trigger as many as 98 thousand deaths annually.

These sleep-deprived individuals are also at greater risk of motor vehicle crashes, near misses, and traffic violations.  As we have discussed in a previous article, specific risk factors for drowsy-driving crashes are sleeping less than 5 hours per night, feeling sleepy, and having been awake for more than 20 hours immediately prior to the crash.  These accidents frequently occur between 4:00 am and 8:00 am, when human performance is at its lowest.

One study found that more than half of nearly 1,000 emergency medicine residents reported one or more near-crashes, and 8% had been in 96 crashes, the vast majority occurring after a night shift.

A major study is scheduled to begin that will examine the impact of a schedule that will be designed to minimize sleep deprivation of interns in a 3 week rotation.  The researchers will compare the performance and health of these interns against a control group of those working the current national standard ICU resident work schedule.  Charles Czeisler, PhD, MD, who directs Brigham and Women’s Hospital in Boston division of sleep medicine will conduct the study along with colleagues at the Harvard Medical School.

One might assume that the study will demonstrate the fallacies of having physicians-in-training working these ridiculous shifts.  But there is support, or explanation, for the status quo among those in the medical community.  Lazar Greenfield, MD, chair of the surgery department at the University or Michigan School of Medicine explains that when complications occur in a patient a resident has operated on, it’s important for the resident to follow through and see what the problem was.  The hallmark of graduate education in surgery, he asserts, is commitment to patient care without regard to time, day of the week hours, worked, or on-call schedule.

Hmmm.  I light of what we know about shiftwork and sleep debt, it makes me wonder who would volunteer to be operated on by a resident. 

At any rate, the State of New York is currently the only state with resident work-hour regulations.  Adopted in 1989, its rules limit residents’ workweeks to 80 hours and shifts with a maximum of 24 hours.    That still seems excessive to me, but if that were the ultimate limits of work hours, I don’t see how the medical establishment could justify anything greater.

 I will be watching the news for results of the study being planned that limits work hours to reduce sleep deprivation among interns.  My guess is that the results will yield fewer patient complications, injuries, and deaths.  I hope the numbers drop into the statistically significant range, and will serve to help eliminate this dangerous practice of physician and patient abuse.

Lamberg, Lynne. Long Hours, Little Sleep:  Bad Medicine for Physicians-in-Training?  Journal of the American Medical Association, Chicago.  January 16, 2002.

Kohn, L.T. et.al.  To Err is Human.  Washington, D.C. National Academy Press, 2000.

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