Better Safe Than Tired?

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By: Ekaterina An and Meital Yerushalmi

The path to becoming a physician is marked with many important milestones: the White Coat Ceremony, reciting the Hippocratic Oath at graduation, and commencing residency training. This process involves an extraordinary amount of hard work and determination. Yet, integral to the job is an issue that has sparked much controversy over the years: sleep deprivation among resident physicians.

We have come a long way since the days resident physicians were, quite literally, residents. In 1889, with the inception of residency training in the United States, residents lived at the hospital and were expected not to marry. William Halsted was one of John Hopkins’ “Big Four” founding professors and became the first chief of surgery in the 1890s. He created the first surgical residency training program in the United States, which required residents to be on call 362 days of the year. However, it was later revealed that he maintained his arduous work schedule with the aid of cocaine. Work ethic aside, the debate continues surrounding the impact of the extensive work hours during residency on patients and physicians alike.

The many sacrifices made by physicians to place patient care above all else have fueled their societal image of part martyr, part hero. It may, then, be ironic that at times the prevailing culture among residents of working themselves to the limit seemingly contradicts the cornerstone of medicine, primum non nocere: above all, do no harm. Perhaps the most notable case which brought this issue to the headlines was that of Libby Zion. In 1984, the 18-year-old was admitted to the New York Hospital with a fever, agitation, and disorientation. She was evaluated by a resident and an intern, prescribed meperidine, a painkiller and a sedative, and subsequently haloperidol, an anti-psychotic. A few hours later, Zion’s fever became dangerously high and she died of a cardiac arrest.1

When Zion’s father, a columnist for The Daily Times, learned that his daughter’s doctors had been on duty for nearly 24 hours when they evaluated her, and that residents were routinely awake for over 36 hours, he sued the hospital and the doctors, and publicized the circumstances he believed led to her death.2

Subsequently, public awareness increased and reforms followed. In 1989, New York State limited resident work hours to 80 per week, a restriction later imposed by the Accreditation Council for Graduate Medical Education (ACGME) on all US training programs in 2003. The ACGME also prohibited direct patient care after 24 hours of duty, and mandated at least one day off per week.2 While reforms took place widely in the US, Canadian policies remained largely unchanged. The only exception was Quebec, where the Fédération des médecins résidents du Québec (FMRQ) successfully reduced on-call shift hours from 36 to 24 in 1984.3

In addition to sparking reforms to resident duty hours, the Libby Zion case highlighted the presumed dangers of sleepless 24-hour shifts. Her death has encouraged the formation of numerous expert committees, panels, and studies to examine the impact of sleep deprived and fatigued residents on patient safety and physician health.

It has been long recognized that sleep plays a key restorative role in maintaining effective neurocognitive performance. Lack of sleep diminishes alertness and neurocognitive function: 24 hours of sleep deprivation led to an impairment of neurobehavioural performance on par with a blood alcohol level of 0.10%.4 Sleep deprivation can also result in a loss of situational awareness, fatigue amnesia, grogginess,4 higher risk of car accidents, hospital-related injuries or infections, and compromised mental health.5 Empirical evidence of the detrimental impact of fatigue and sleep deprivation on cognition supported the argument against extensive resident duty hours. Yet, specific evidence was still needed to demonstrate the impact of sleep deprivation on patient and resident outcomes. The Intern Sleep and Patient Safety Study 6,7 set out to elucidate the consequences of sleep deprivation; the study compared the traditional 30-hour shift with a 16-hour maximum intervention shift schedule. The authors found that attentional failures (slow-rolling eye movements that occur at the transition from wakefulness to sleep) were more than doubled during night shifts on the traditional schedule.6 Additionally, interns made 36% more serious medical errors (medication, procedural, and diagnostic errors that cause or have the potential to cause harm) during the traditional 30-hour shift.7 More recently, the Canadian National Steering Committee on Resident Duty Hours reported that continuous 24-hour shifts pose risks to the “physical, mental, and occupational health of residents.”8 The amassed empirical evidence seems to clearly indicate that the fatigue and sleep deprivation that accompany long shifts have serious, negative effects on physicians’ safety and cognition.

It may come as a surprise, then, that the regulations to restrict resident duty hours have not resulted in the expected improvement in patient outcomes. A recent randomized trial of 117 general surgery residency programs in the United States examined the impact of duty-hour restrictions on both patient and resident outcomes.9 Participating programs were assigned to either the current ACGME standard duty hours (a maximum of 16 hours per shift in the first year of training, and 28 hours thereafter) or flexible duty hours that may exceed the aforementioned restrictions per shift. Participating programs in both groups were to limit their residents’ duty hours to 80 per week and on-call frequency to every third night; in addition to one day off per week. Interestingly, residents in programs assigned to flexible duty hours reported benefits with respect to continuity of care, surgical training, and professionalism without an appreciable difference in resident safety, leading the authors to conclude that flexible hours result in non-inferior patient outcomes.9 Furthermore, a systematic review concluded that reduction in duty hours negatively affects patient care.10

Another matter that must be considered when assessing the impact of different policies is resident education. Achieving mastery in surgery requires extensive and immersive experience, 11 as does the practice of medicine as a whole. Residents, serving the dual role of health care providers and learners, acquire the skills and knowledge of their specialty while practicing under the supervision of experienced staff physicians and through independent study. While some studies demonstrate that restricted duty hours result in improved examination scores12 and allow more time for independent study and knowledge acquisition,13 residents reported similar satisfaction rates with respect to their quality of education under restricted and flexible duty hours.9 Similarly, a systematic review found no evidence of improved educational or training experiences with 16-hour duty caps. In fact, a multitude of studies demonstrate a decline in performance on some certification exams following regulations to limit duty hours.14 As with most aspects of this debate, data and opinions are conflicted.

So the question remains of whether duty hour restrictions improve patient and resident outcomes. When blanket duty-hour restrictions were first implemented, there was little empirical support for the benefits of shorter shifts. However, with the widespread implementation of duty-hour regulations, we are starting to recognize additional factors that influence patient care and safety. One of the most common arguments against duty-hour restrictions is the resultant decrease in continuity of care. Shorter shifts mean that more doctors are responsible for the care of a single patient¾as one doctor leaves, another one must take over. Patient handoff procedures are not standardized and create more opportunities for medical errors. In fact, patient handoffs are one of the most preventable causes of serious medical errors and patient harm.15

Additionally, most of the aforementioned studies were conducted in surgical residency programs, as this field has been impacted extensively by duty-hour restrictions, with residents being asked to leave the hospital mid-surgery or transfer patient care in the middle of an emergency situation because their shift was up.16 This example, whereby a resident leaves a case mid-surgery as a result of duty-hour restrictions, serves to illustrate the dissonance between residency training and general practice. Furthermore, in revisiting the case of Libby Zion, it is clear that multiple factors led to the circumstances of her death: intern fatigue, minimal supervision, and a lack of safeguards against a fatal drug interaction. Although fatigue and sleep deprivation play a role in adverse patient outcomes, some experts suggest that other factors are at play which may exacerbate and compound the impact of sleep deprivation: inadequate supervision17 and limited experience of residents in complex cases.10

Undoubtedly, the debate surrounding resident duty hours is a complex and multifaceted one. While the physiological and mental effects of sleep deprivation were used to promote policies that restrict resident duty hours, several studies failed to show a consistent association with improvement in resident well-being and patient outcomes. Whether or not duty-hour restrictions are implemented, experts have suggested several ways to enhance patient outcomes and improve resident education that address other underlying issues. For example, medical errors and preventable adverse events decreased by 23% and 30%, respectively, with the implementation of a handoff-training intervention.18 In fact, an evidence-based standardized approach to improving handoff procedure has been developed.19 Another avenue that may be explored in enhancing training opportunities is simulations aimed at improving various interventional and surgical techniques. Though their impact on patient outcomes remains unknown, such simulations can be utilized in programs where duty-hour restrictions limit hands-on experience.10 Furthermore, technology can also be implemented to avoid the issue of drug interaction by implementing computerized prescribing systems that automatically alert physicians to potential drug interactions.2 Further, some experts also recommend the implementation of strategies to deal with fatigue, such as strategic napping and alertness management,20 as well as screening and addressing resident burnout and improving scheduling practices to optimize sleep.10 In fact, another trial is currently comparing the effect of different scheduling practices on patient safety and trainee education.21 In line with the recommendations above, the Canadian Medical Association and the Canadian National Committee on Resident Duty Hours have shifted from strict, blanket reductions in resident duty hours to a more integrated and flexible approach.22 Whether or not these recommendations are implemented effectively in Canadian residency programs remains to be seen; surely, decision makers will need to sleep on it.

References:

  1. Lerner, B. A case that shook medicine. The Washington Post [Internet]. 2006 Nov 28 [cited 2016 May 30]. Available from: http://www.washingtonpost.com/wp-dyn/content/article/2006/11/24/AR2006112400985.html
  2. Sanghavi, D. The phantom menace of sleep-deprived doctors. The New York Times Magazine [Internet]. 2011 Aug 5 [cited on 2016 May 30]. Available from: http://www.nytimes.com/2011/08/07/magazine/the-phantom-menace-of-sleep-deprived-doctors.html?_r=5
  3. Lajoie MR. End of 24-hour institutional on-call duty in Quebec A measure even practising physicians are calling for. Can Fam Physician. 2012 May 1;58(5):e296-7.
  4. Cziesler, C. The Gordon WIlson Lecture: Work hours, Sleep, and Patient Safety in Residency Training Trans Am Clin Climatol Assoc. 2006 117:159-188.
  5. Comondore VR, Wenner JB, Ayas NT. The impact of sleep deprivation in resident physicians on physician and patient safety: Is it time for a wake-up call?. BCMJ; 2008 50(10): 560-564.
  6. Lockley SW, Cronin JW, Evan EE, Cade BE, Lee CJ, Landrigan, CP et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med. 2004 Oct;351:1829-1837 doi:1056/NEJMoa041404
  7. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004 Oct;351:1838-1848 doi: 10.1056/NEJMoa041406
  8. National Steering Committee on Resident Duty Hours. Fatigue, Risk and Excellence: Towards a Pan-Canadian Consensus on Resident Duty Hours. Ottawa, Ontario: The Royal College of Physicians and Surgeons of Canada; 2013.
  9. Bilimora KY, Chung JW, Hedges LV, Dahlke AR, Love R, Cohen M et al. National Cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016 Feb; 647:713-727 doi:10.1056/NEJMoa1515724
  10. Ahmed N, Devitt KS, Keshet I, Imrie K, Feldman L, Cools-Lartique J et al. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg. 2014 Jun;259(6):1041-1053 doi: 10.1097/SLA.0000000000000595
  11. American College of Surgeons Task Force. Position of the Americal College of Surgeons on restrictions on resident work hours. Bull Am Coll Surg. 2009 Jan;94(1): 11-18
  12. Durkin ET, McDonald R, Munoz A, Mahvi D. The impact of work hour restrictions on surgical resident education. J Surg Educ. 2008 Jan; 65(1):54-60 doi:10.1016/j.jsurg.2007.08.008.
  13. Accreditation Council for Graduate Medical Education: Duty Hours Subcommittee Report. Chicago: Accreditation Council for Graduate Medical Education; 2009.
  14. Imrie K, Frank JR, Ahmed N, Gorman L, Harris KA. A new era for resident duty hours is surgery calls for greater emphasis on resident wellness. Can J Surg. 2013 Oct; 56(5):295-296 doi: 1503/cjs.017713
  15. American College of Surgeons. Reform to resident physicians’ work hours does not improve surgical patient safety. Chicago, IL: American College of Surgeons
  16. Weissmann J. Years ago, we decided that young doctors need more sleep. The plan might have backfired. Slate [Internet]. 2015 Dec [cited on 2016 May 30]. Available from: http://www.slate.com/blogs/the_drift/2015/12/02/young_doctors_needed_more_sleep_but_the_plan_for_them_to_get_it_might_have.html
  17. Bell BM. Supervision, not regulation of hours, is the key to improving the quality of patient care. JAMA. 1993 Jan 20;269(3):403-4.
  18. Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014 Nov;371:1803-1812 doi:10.1056/NEJMsa1405556
  19. I-PASS Handoff Study [Internet]. Boston: I-PASS Study Group/Boston Children’s Hospital. 2014 [cited on 2016 May 30]. Available from: http://www.ipasshandoffstudy.com/about
  20. Rosenbaum L, Lamas D. Residents’ Duty Hours – toward an empirical narrative. N Engl J Med. 2012 Nov; 367:2044-2049 doi:10.1056/NEJMsr1210160
  21. iCOMPARE Study Executive Summary [Internet]. Boston: Brighman and Woman’s Hospital/Harvard Medical School. 2014 Sep [cited on 2016 May 30]. Available from: http://www.jhcct.org/icompare/docs/iCOMPARE%20-%20Design%20Summary%20(20140908).pdf
  22. Canadian Medical Association. Management of physician fatigue. Ottawa, Ontario: Canadian Medical Association; 2014. Available from:http://policybase.cma.ca/dbtw-wpd%5CPolicypdf%5CPD14-09.pdf