Would you let a doctor treat you if you knew she’d had three vodka tonics? How about a doctor who hadn’t touched alcohol, but had worked 80 hours this week, including an all-nighter?
Both, a new study of medical residents suggests, would be in roughly the same shape: less alert than usual, more prone to error, distractible. And while on a computerized attention test, they scored similarly, on a driving simulator, the fatigued ones did worse.
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The study, conducted by Brown Medical School experts and published in last Wednesday’s edition of the Journal of the American Medical Association, builds on previous research that has already led hospitals across the country to reduce their residents’ work hours.
In July 2003, while the study was under way, the Accreditation Council for Graduate Medical Education imposed an 80-hour-a-week limit on the nation’s roughly 98,000 medical residents. But some, including the study’s authors, believe that’s not enough.
“The take-home message here is that the repercussions of fatigue on residents are considerable,” said Judith Owens, director of the Pediatric Sleep Disorders Clinic at Hasbro Children’s Hospital and associate professor of pediatrics at Brown Medical School. “This is a national problem, and we shouldn’t consider it solved by an 80-hour cap on hours.”
The study involved 34 pediatric residents at an unidentified academic medical center. They were tested after light call rotation (four-week rotations averaging 44 hours per week), light call with alcohol (just enough for a 0.05 blood-alcohol level), heavy call (an average of 90 hours per week, including overnight duty, or 80 hours after July 2003), and heavy call with placebo. After each test, the residents were asked to evaluate their own performance.
The heavy-call residents, the study found, did far worse than the light-call residents who hadn’t drunk alcohol, and about the same as those who had drunk: They had 7 percent slower reaction times, and their lane variability on the driving simulator was 27 percent greater. Their speed variability was much worse, 71 percent greater than for the sober light-call residents, and 29 percent greater than for the mildly intoxicated ones.
The study also found the residents had only a “limited” ability to judge their own impairment, especially when it came to reaction times, rather than driving skill. And though some claimed to have adapted to the effects of chronic sleep loss, the results didn’t bear that out.
The authors acknowledged that their tests hadn’t directly measured residents’ performance in a clinical setting, or even in real-life driving. However, they noted, the results are consistent with previous reports of sleep-deprived residents making more mistakes and having far more car crashes and near-misses than the general population.
Owens, a pediatrician who was in a serious car crash herself when she was a resident, helped create the Sleep, Alertness and Fatigue Education in Residency (SAFER) Program used in residency programs across the nation. But more needs to be done, she said, to educate doctors-in-training about the risks of sleep deprivation and to help reduce those risks.
Mary A. Carskadon, director of the Bradley Hospital Sleep and Chronobiology Research Lab, professor of psychiatry and human behavior at Brown Medical School, and a co-author of the study, along with former Brown Medical School researcher J. Todd Arnedt (now at the University of Michigan Ann Arbor), said cutting residents’ hours isn’t the only solution.
“We could improve on-call sleeping quarters, provide rides to and from work, reinforce the importance of catching up on sleep after heavy call,” Carskadon said. “Because there is a risk to residents and to other drivers – and that risk needs to be managed.”
With two colleagues directly involved in this study, Dr. John Murphy, director of graduate medical education for Rhode Island Hospital, Miriam Hospital and Bradley Hospital, is particularly aware of the issues, and he said even before the study was completed, his office had taken several steps to address the problem.
Following the accreditation council’s guidelines, the hospitals not only reduced work shifts to fit within the 80-hour cap, but also reduced the maximum length of individual shifts, required that residents get at least 10 hours off in between shifts, and strengthened supervision so that residents don’t spend a lot of time “moonlighting,” Murphy said.
Some departments have gone even further, he said: In pediatrics and internal medicine, for example, most residents don’t work overnight shifts anymore, but rather there are day teams and night teams. Emergency medicine, being extra-demanding, has even lower caps for individual shifts and for hours-per-week. In addition, Murphy’s office sponsors educational programs about fatigue, and it monitors residents’ well-being through anonymous surveys.
But someone still needs to care for the patients, and to take some of the load off the residents, the hospitals have had to hire more doctors, more nurse practitioners, more physician assistants, and it’s had to shift some of the work to fellows, Murphy said. All that has a price.
“As an institution, this was an important step for us to take, and we probably need to continue to move forward, but it was very expensive,” Murphy said.
