Hey Doc, No Sleep For You!
Today's post is the last in a three-part series on the importance of sleep, this entry focusing on new regulations for medical residents' work hours as devised and implemented by the Accreditation Council for Graduate Medical Education, the organization that has oversight authority for medical residency programs across the United States. These new regulations were approved and went effect on July 1 of this year. I learned about this change in policy from an article titled "New doctors could work 28 hours straight under proposal" by Melody Peterson of The Los Angeles Times (originally published Dec. 16, 2016) and much of the info I will share in this post comes from that article, except for personal experiences and policy language directly from the ACGME itself.
First some history: prior to 2003, there were no standardized national regulations or limits concerning medical residents' workload. Indeed, the term "resident physician" comes from the fact that doctors fresh out of med school usually lived at the hospital where they received clinical training before striking out on their own. New York was the first state to limit the amount of time medical residents can work following the death of a young patient in the care of sleep-deprived, over-worked, error-prone interns. The girl's family sued the hospital and the father, Sidney Zion, wrote in a New York Times op-ed, "You don't need kindergarten to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call- forget about life-or-death" (to which I say 'Amen Mr. Zion')." New York State followed by passing a 1989 law banning residents from working more than 80 hours a week or shifts longer than 24 hours.
However, it was not until 2003 that the ACGME first approved and implemented a national standard of an 80-hour workweek and shifts no more than 24 hours. But then the Institute of Medicine published results of a year-long review in 2009 that concluded "having doctors work more than 16 consecutive hours was dangerous for both patients and doctors," prompting the ACGME to revise its policy. In 2011 residents were banned from working more than 16-hour shifts. This caused problems for hospitals, however, because medical residents are treated almost like indentured servants. Hospitals receive fixed amounts of money from the federal government to train medical residents. Thus, the more hours worked by residents, the more cost-efficient for the hospital. When I was an intern 20 years ago, we got paid roughly $36,000 a year flat with no overtime. Taking into account the 80-100 hour workweek, residents got paid egregiously below their value and an hourly average on par with employees outside the medical field possessing much less education, knowledge and skill. Furthermore, since residents were required to be at the hospital (physically at least although at various dwindling levels mentally) they were often taken advantage of by other physicians.
Here is one example from my time as a medical intern. Community-based physicians may receive a call from the hospital regarding a private patient in their care. The doctor may order a test, such as a lab test or an X-ray. Lab test results can be passed on to the doctor by the lab technician performing the test, but radiology techs are not legally allowed to "read" or interpret X-rays. At the hospital I worked at, radiologists did not work overnight, so if an X-ray was ordered at say 2 am and the ordering doctor wanted to know the results right away, he or she could ask for the medical intern on call that night, and did not matter if that intern was sleeping, the pager would go off and the doc would ask the intern to go read the X-ray, despite the fact you had never seen the patient before and thus lack context except for what the doc tells you over the phone. Then the intern, regardless of how groggy he or she is has to trudge through the hospital to the radiology department, get the X-ray, and do your best to interpret what you see and tell the doctor calling from home because he/she does not want to drag their ass out of bed and drive to the hospital to care for their own patient, when a medical intern is already there- never mind how little sleep he/she has had, has had no contact with the patient, and has little experience interpreting X-rays since they are barely out of medical school and NOT a radiologist. That happened to me multiple times during my internship year, and every time it made me FUCKING FURIOUS!!!!! because I had enough on my plate than to leap out of bed to do a goddamn favor for some doctor I had never met simply because he/she was in a position to use (abuse) me. This type of deal has long gone on in medicine, but in my mind it does not make it right.
After 2011, when interns were limited to 16-hour shifts and 80-hour workweeks, many hospitals complained about the new policy. These hospitals had become dependent on the cheap labor of medical residents and squeezing brutal hours out of them. Now left with the same amount of money from the federal government for training expenses, but forced to hire outside physicians to "moonlight"- pick up odd shifts at night to fill in the gaps caused by the ban on medical residents working 24-hour shifts- which they had to pay for out of their own budget, hospitals began suffering financial difficulties. So the hospital industry groups spent loads of money to hire lobbyists to put pressure on the ACGME to roll back the regulations on medical residents' work schedules.
The ACGME indeed established a blue-ribbon panel of physicians to research the pros and cons of the 2011 regulations. The panel came to the conclusion that a 16-hour shift limit was arbitrary in terms of the effectiveness of the care provided by medical interns while the ban on longer shifts damaged the educational value because residents needed to be more exposed to the continuity of care, the progression of clinical cases, and they must become accustomed to the challenging environment they may face after residency when they would no longer be supervised. Thus, the official policy as laid out in the organization's article titled The 2017 ACGME Common Work Hour Standards: Promoting Physician Learning and Professional Development in a Safe, Humane Environment-
"The new program requirements allow up to 4 additional hours at the end of the 24-hour limit for transitioning care and formal didactics...The 2017 requirements provide residents with added flexibility over schedules, allowing them to remain on a voluntary basis beyond the 24-hour maximum..."
The good thing about the new regs is that it continues the 80-hour maximum workweek. However, I find both the title of the article and the suggestion that working more than 24 hours be "voluntary" laughably misleading if not downright false. First of all, though the policy does require medical residents to receive training about recognizing the effects of sleep-deprivation, including poor judgment, slowed reactions and increased risk of car accidents on the way home, depression and suicidal thoughts, and requires counseling and mental health treatment be available to residents on a 24-hour basis, based on all that is now known about the terrible effects of sleep-deprivation, I just don't see how forcing medical residents to work up to 28-hour shifts is humane or safe. Also I find the "voluntary" nature of staying beyond 24 hours ridiculous. If one resident always insists on leaving after 24 hours because he/she is tired out, but other residents in the program stay on for 28 hours regularly, how do you think the other residents and the supervising attendant physicians are going to feel towards that one resident who always bolts after 24 hours? From experience, I know it would not look good, and that resident is going to be viewed in a bad light by everyone else.
Here is some more info from that 2016 Los Angeles Times article:
"Studies show that residents make more potentially deadly errors in caring for patients the longer they work."
"Charles Czeisler, a professor at Harvard's Brigham & Women's Hospital, who has studied what happens as residents work extended hours... in one trial, Czeisler and his colleagues found that interns working in the ICU for 24 hours or more made 36% more serious medical errors than those working shorter shifts. At times, the researchers even found residents sleeping while standing up"(!)
Professor Czeisler, in response to the new regulations said, "This is deeply troubling. It is very well established that staying awake for 24 hours severely degrades performance." (To which I second that sentiment by saying NO FUCKING DUH!)
"The extended shifts also expose residents to an increased risk of car accidents as they drive home from work. At the UCLA clinical training program, nearly 20% of residents said in a 2007 survey that they had fallen asleep while driving because of work-related fatigue." (That is one out of five, people- an inexcusably high rate of placing themselves and other drivers on the road at risk- and I not only fell asleep but was extremely lucky to not get seriously injured or killed by an accident I mentioned in last week's blog post.)
Now for some background on my own experience. I graduated from U.B. medical school and began a family medicine residency in Erie, Pa. in 1997. As I stated in last week's post interns were required to work 34-hour shifts on average every four days, which resulted in workweeks of 80-100 hours depending on the rotation one was assigned. While on call the intern was not allowed to leave the hospital- not even to go outside for some fresh air for a few minutes. It got to the point during my internship that I felt trapped and even thought I would prefer to be in prison because at least inmates get a decent night's sleep every day and are not subject to the extreme stress of having to make critical life-and-death decisions for other people. Even on "slow" nights it was hard to fall asleep due to the anxiety of knowing that at any second the pager could go off with an emergency situation to deal with. Here is a clear example of PTSD- for years after I quit medical residency, the sound of a pager beeping involuntarily induced my heart to temporarily stop then go into palpitations and my hands to tremble for a few seconds before my brain realized that I was no longer an intern responding to a call.
It doesn't have to be that way. During my fourth year of medical school I did a family medicine inpatient rotation at Millard Fillmore Suburban Hospital. There I saw how residents in the Buffalo family medicine residency program were trained. Due to the 1989 New York State law, residents were banned from working more than 24 hours straight. So when a resident was on call, they worked a normal 10-hour shift then went home for the night after updating the moonlight physician on the patients currently on the family medicine inpatient service. The resident then took calls from home and had to return to the hospital only if a new patient had to be admitted from the ER or a pregnant woman arrived in labor. On those nights when a resident had to come into the hospital and thus did not get much sleep, they would participate in morning rounds, then get to go home to rest. It was much more reasonable and humane than the schedule at the Pennsylvania hospital where I worked, and also more in line with how physicians in group practices take call. Knowing how the Buffalo program worked and how much better it was than the set-up in Erie gnawed at me as the year went on.
So why did I choose Erie over Buffalo? That is too complicated to fully answer here, but the bottom line was that I had spent my entire life and academic career in Buffalo and I thought it important to get away from home, including all the distractions of family, to be more independent and concentrate fully on work, and besides I had participated in a summer program at that Erie hospital between my 1st and 2nd years of medical school and I really liked the faculty and the facilities. So I chose Erie because I figured it was the best of both worlds- far enough from Buffalo to separate myself from family but also close enough that I could drive home one or two weekends a month to visit. It became clear within a few months, however, as the excruciating toll of working frequent 34-hour shifts weighed upon me, and the anxiety, depression and suicidal thoughts built up to the point where I was incapacitated, that I very well had made a critical mistake in choosing the Erie program. But by that point it was too late- I had been scarred for life. There were other factors that led me to abandon my dream of becoming a practicing physician- in particular my tremendous fear of making an error that would harm or kill a patient that led to a time-consuming and suffocating "paralysis by analysis"- but there is no doubt that the sleep-deprivation and claustrophobic squeeze of being forced to work 34-hour shifts without any pause from constant anxiety was the premier reason.
There are clear positives for patients in the continuity of care. Indeed the argument for longer shifts by medical residents is that errors occur when a moonlight physician comes in to cover overnight and does not know the patients as well as the medical residents. Fair enough. But at what point does the advantage of continuity of care surrender to the inevitable mistakes made by sleep-deprived residents? The 2009 Institute of Medicine study concluded that 24-hour shifts caused harm to both the patient and the resident physician. That led to the 2011 ACGME policy of 16-hour shift limits. That decision harmed teaching hospitals' bottom line so they collectively lobbied the ACGME to change this policy. Now here in 2017, medical residents are back to being coerced to work up to 28 consecutive hours. I admittedly don't know how much better it is for patient care than 16-hour limits, but there is no doubt that it is far worse for medical residents' mental health and increases the risk for more car accidents and suicides.
In conclusion, had I fully known when I was a naive 18-year-old what I was getting myself into with regards to clinical training, I would not have attended medical school, dropped myself into a $100,000 financial hole I seemingly will never escape, and suffered from the permanent ravages of depression and post traumatic stress disorder rendered by medical residency. So in response to this new requirement of 28-hour shifts I just have one last thing to say: FUCK THE ACGME!