There has been much hand-wringing over the dangers of medical residents’ grueling schedules. Doctors-in-training often forgo sleep entirely, racking up as many as 30 work hours in a single stretch. The term “resident” is in fact no accident, says Dr. Teryl Nuckols, an internist and assistant professor at the David Geffen School of Medicine at University of California, Los Angeles, who says that when she was in training 10 years ago, 36-hour shifts without rest were common. “[Residents] used to live in the hospital,” Nuckols says. “They were there 24/7.”
The issue is whether their presence on the hospital floor, dizzy with exhaustion, is a help or a hazard. An oft-cited 2004 study of intensive care units found that medical residents made 36% more serious mistakes during 30-hour shifts than during shifts half as long. So, the simple solution to ensuring patient safety — and resident sanity — would appear to be reducing the length of their shifts, a plan endorsed by a lengthy Institute of Medicine report in December of 2008, which assessed the impact of resident fatigue, and proposed a new set of guidelines restricting shifts to 16 continuous hours if no rest is granted, mandatory uninterrupted five-hour naps for longer work sessions, lighter workloads and more oversight from experienced physicians.
“If you follow our report and put it into practice, residents would have greater opportunity to get more sleep,” says Dr. Michael M.E. Johns, chair of the residency optimization committee at the IOM and chancellor of Emory University. “[Residents] would also have increased supervision by experienced doctors.”
But many in the medical community, including residents themselves, worry that shorter shifts could come at the cost of educational opportunities and possibly even patient safety. And implementing the changes wouldn’t be cheap, potentially costing teaching hospitals $1.6 billion a year, according to a study co-authored by Nuckols and published this week in the New England Journal of Medicine.
Instituting the measures could be a boon for society, however, potentially reducing the overall costs of errors — which can result in subsequent hospital visits, extra post-treatment care and lost wages — to almost negligible levels, but that’s only the case if the new policies can decrease the rate of preventable errors by at least 11.3%, according the study.
“Medical errors are expensive, and most of the costs of medical errors actually affect people after they leave the hospital,” says Nuckols, who is also a health services researcher for the RAND corporation, the nonprofit health research group that sponsored the study. “If the recommendations do succeed at reducing medical errors, there could be some cost offsets.”
There is no guarantee, however, that limiting residents’ shifts is the key to patient safety. Dr. Kenneth Polonsky, chairman of the Department of Medicine at Washington University in St. Louis, who co-wrote an editorial accompanying Nuckols’s study in the New England Journal, says that while some studies show a correlation between fatigue and mistakes, not all studies reach the same conclusion. What’s more, Nuckols says, studies aimed at determining the cause of a mistake are inherently complicated: they require highly skilled researchers to pinpoint exactly what went wrong and when, and many rely on self-reporting from residents who, for obvious reasons, would sooner attribute a mistake to exhaustion than other factors.
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