Sometimes it’s so easy to blow holes in an argument, you wonder if you’re on Candid Camera. Such is the case with the recently announced proposal by the Accreditation Council for Graduate Medical Education (ACGME) to let residents work longer than 28 consecutive hours in a shift, eliminating the current 16-hour shift restriction. The rule, if approved, would eliminate the requirement that residents get at least eight hours off after shifts of less than 24 hours. Some of the arguments in favor of this rule, despite reams of research to the contrary, are almost laughable.
Check out the arguments the Council makes in favor of the new rule, with reactions gleaned from the SDN forum:
–> The plan keeps rules in place that restrict residents from working more than 80 hours a week averaged over four weeks. So, they’ll no longer have to work any more than 80 hours a week.
“It sounds like it would be better, but it’s not. You’re a lot more exhausted by a 28-hour shift than you are by night float. I’d rather be able to get to sleep every 16 hours and deal with night float. I think that’s far healthier and more humane. Not to mention in our program, the 28 hour calls that residents have to do means that the interns are left alone to manage all the patients, including the new patients the resident admitted overnight that we know nothing about and the resident is too exhausted to help us with in the morning, after the resident goes home.”
–> If the new rule is passed hospitals must begin providing 24-hour access to affordable mental health treatment to residents.
“This is like saying, well we’re going to pour 5 gallons of gas on the fire, but we’re going to give you a dixie cup of water to have at your side, so it should be a net wash.”
“Well-trained doctors are no good to anyone if they are dead or so damaged that they must exit the profession. Well being of the trainees has to be taken into account too.”
–> “Training to become a practicing physician can be compared to training for a marathon,” said Thomas Nasca, chief executive of ACGME. “With enough experience comes resilience and the ability to perform under expected, sometimes challenging, conditions.”
“It’s just forcing us to do it because the older decision makers had it forced on them. It’s not good for anyone or the attending would still be doing it and they largely put an end to that crap the second they graduate in most fields.”
–> Restrictions on how many hours residents can work have been expensive to teaching hospitals, which had to hire more staff to do work once performed by the physician trainees.
“If the only way to have a financially solid department is to rely on trainees to work very long hours, then there’s a serious issue with the system.”
“It’s ridiculous to say that there isn’t a lot of money so the people adding to their plate are the only ones that work extra hours for free and can’t speak up. So in regards to the system saying they need certain hours covered…too bad. The system doesn’t get to lay it on the feet of the powerless…patient care costs money and it’s not the resident’s problem to try and make it free.”
Don’t crash – drink coffee.
Some medical schools look like they really believe that Starbucks will suffice, when in actuality sleep is the only thing preventing some residents from crashing on the way home. At UCLA, nearly 20% of residents said in a 2007 survey that they had fallen asleep while driving because of work-related fatigue. The college website says that residents are taught to recognize when they are sleep deprived by telltale symptoms like: “Dozing off while writing notes or reviewing patients’ medications, and poor memory or judgment.” As the LA Times reported, “UCLA residents are told that lack of sleep can cause hostility, high blood pressure and a higher risk of car accidents on the drive home.” And yet, one tip is to drink coffee 30 minutes before driving home.
This is deeply troubling
The voice of reason comes not only from reemes of research, but from Charles Czeisler, a professor at Harvard’s Brigham & Women’s Hospital, who has studied what happens as residents work extended hours.
“This is deeply troubling,” he said. “It is very well established that staying awake for 24 hours severely degrades performance.”
“This is deeply troubling,” he said. “It is very well established that staying awake for 24 hours severely degrades performance.”
Czeisler and his colleagues have conducted numerous trials in this area and found that interns working in the ICU for 24 hours or more made 36% more serious medical errors than those working shorter shifts.
Stay for surgery
Surgeons have been especially critical of the existing shift restrictions, which they say have required some residents to leave in the middle of a surgical procedure. They say that’s bad for patients. “Baloney” says a study published in the New England Journal of Medicine.
“The FIRST Trial (Flexibility in Duty Hour Requirements for Surgical Trainees) effectively debunks concerns that patients will suffer as a result of increased handoffs and breaks in the continuity of care. Rather than backtrack on the ACGME duty-hour rules, surgical leaders should focus on developing safe, resilient health systems that do not depend on overworked resident physicians. They should also recognize the changing expectations of postmillennial learners. To many current residents and medical students 80-hour (or even 72-hour) workweeks and 24-hour shifts probably seem long enough. Although few surgical residents would ever acknowledge this publicly, I’m sure that many love to hear, ‘We can take care of this case without you. Go home, see your family, and come in fresh tomorrow.'”
Sleep Deprivation Cocktail
You want studies on how sleep deprivation and residents can result in a toxic cocktail? Looking for research that shows a direct link between sleep deprivation and an adverse impact on patient care is like walking shore to shore across a brook full of trout- you just have to poke the surface to find what you are looking for. Here’s a sampling from the Sage Journal, Science Direct, the Journal of Occupational and Environmental Medicine, and the Journal of the American Society of Anesthesiologists.
Show me the money
However, we all know the power of the almighty dollar and that might be the dark force at work here. Look at the math as reported by the LA Times: “Medicare pays the teaching hospitals as much as $130,000 or more a year for each resident. The hospitals then pay residents just a fraction of that, with many receiving a salary of around $60,000, with no overtime. After covering the cost of the residents’ benefits, the hospitals can use the money for other purposes.”
However, if shifts are limited and hospitals have to hire clinicians to fill in for resting residents, then the profit margin goes down. According to the Times, “Nasca said the council had “extensive” policies in place to deal with any potential conflicts.”
The Council collected comments on its website, acgme.org but that window has closed. A final vote on the proposed rule change is expected in February.
Then it will either be time for the clown car for residents, or a reaffirmation that residents are human too, and need sleep in order to care for and protect their patients.
