Over a quarter century ago, a young woman was admitted to a New York hospital with fever and agitation. She never walked out. Libby Zion died while under the care of he primary care doctor and two medical residents. The exact cause of death was never identified, but the case led to a forced examination of medical residents' work hours. This was driven largely by Zion's father who felt that his daughter had been killed by inexperienced, poorly supervised, and overworked resident physicians.
"You don't need kindergarten," he wrote in a New York Times op-ed piece, "to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call -- forget about life-and-death."
It was largely thanks to Zion's tireless work that in 1989 a bill was passed in New York State limiting resident work hours and requiring senior physicians to be physically present in the hospital. But though you might not need kindergarten to recognize this problem, you do need data. That came later.
Medical residents have traditionally worked long hours, especially in their first ("intern") year. In fact, they used to "reside" in the hospital, and were universally young, male, and single. Now, graduating medical students are about 48% female, compared to just over 26% in 1982 (although age hasn't changed much, which sort of surprised me). The Libby Zion law limited resident work hours to 80 hours per week and 24 hour shifts. During my internship in Chicago, we would typically work about 32 hours in a row on call and post-call, and call took place every fourth night, which has long been typical for internal medicine residencies.
In 2003, the Accreditation Council on Graduate Medical Education (ACGME) instituted the first national work hour limitations for residents. These limitations looked very similar to those imposed by NY state. These work hour limitations required significant changes to how hospitals and residencies were run. Hospitals can only support a certain number of residents, and they count on these residents and the care they provide. Hospitals have had to reduce the number of patients cared for by residents, and has led to an increase in so-called mid-level providers (physician assistants and nurse practitioners). And residencies had to find ways to accomplish the same or similar amount of work with the same personnel but with significant time constraints.
Many of these changes involved a more toward "shift work" and night float systems, where residents worked shifts of limited hours throughout a 24 hour day, handing off patients to the next shift. This creates its own problems for both patients and residents. There are concerns that shift work may lead to a disruption in continuity of care, since patients are being "handed off" potentially several times a day. Also, residents are not supposed to be performing functions that are primarily "service" rather than educational. During the day, residents can break away from clinical duties for educational conferences, but a 11pm-7am shift is all service.
These, and the urgent questions about the safety of both patients and residents were addressed in a comprehensive report released in 2009 by the Institute of Medicine, part of the National Academies. While it makes sense that long sleep-free work hours might be dangerous to both patients and residents, knowing the data allows us to make proper, evidence-based decisions about these potential problems.
As medical educators, we have a duty to our residents to ensure not only their education, but their well-being, at least as it relates to work. It is conceivable that long, sleepless work hours may have adverse health effects. The 2009 IOM report summarizes some of the evidence for fatigue-related injury. Much of this evidence is readily available through PubMed. Needle stick injuries, for example, are a relatively common problem and there is evidence that these are related to fatigue. There is also good evidence that medical residents have an elevated risk for falling asleep at traffic lights and being involved in motor vehicle accidents. And these data are not new.
Data on patient safety isn't new either. A name that pops up again and again in this research is Charles A. Czeisler. He published a study in the New England Journal of Medicine in 2004 showing fairly convincingly that first-year residents in the ICU are at risk of committing significantly more medical errors when working extended shift vs. less onerous ones. That's just one good study of many.
Individual errors are inevitable, but as a phenomenon, errors can be reduced significantly, often through simple systems fixes. One of these fixes is the implementation of reasonable resident work hours.
Responses in the literature and in doctors' lounges have been tangential and almost intentionally obtuse. A colleague of mine at another institution has opined that the medical profession is in a state of "institutional denialism" about the effect of long hours on safety and performance. I don't think that is unfair. The evidence on this has existed for years, yet we've made only cosmetic adjustments to our training programs. Even the latest ACGME rules (which take effect in July 2011) fail to address the most significant implications of the problem. The work hour limitations they mandate will very likely help, but there is a larger systemic problem. Medical training is lengthy and expensive. If we're going to cut back on hours, we need to re-evaluate whether the new hours are sufficient to meet educational needs. If not, we are going to have to find a way to fund longer training programs and to fund the debt-ridden trainees who will spend extra years not paying their educational debt. Quick fixes, even smart ones, aren't going to do the trick.
The Libby Zion case that eventually led to the new work rules was over a quarter century ago. How long will it take us to create real, comprehensive solutions?
Fisman, D., Harris, A., Rubin, M., Sorock, G., & Mittleman, M. (2007). Fatigue Increases the Risk of Injury From Sharp Devices in Medical Trainees: Results From a Case‐Crossover Study• Infection Control and Hospital Epidemiology, 28 (1), 10-17 DOI: 10.1086/510569
Steele, M., Ma, O., Watson, W., Thomas, H., & Muelleman, R. (1999). The Occupational Risk of Motor Vehicle Collisions for Emergency Medicine Residents Academic Emergency Medicine, 6 (10), 1050-1053 DOI: 10.1111/j.1553-2712.1999.tb01191.x
Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE, Czeisler CA, & Harvard Work Hours, Health, and Safety Group (2005). Extended work shifts and the risk of motor vehicle crashes among interns. The New England journal of medicine, 352 (2), 125-34 PMID: 15647575
Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, & Czeisler CA (2004). Effect of reducing interns' work hours on serious medical errors in intensive care units. The New England journal of medicine, 351 (18), 1838-48 PMID: 15509817
Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, & Escarce JJ (2009). Cost implications of reduced work hours and workloads for resident physicians. The New England journal of medicine, 360 (21), 2202-15 PMID: 19458365