Sandeep Jauhar, M.D., Ph.D., is the author of Intern: A Doctor's Initiation, and the director of the Heart Failure Program at Long Island Jewish Medical Center.
It was 3 o'clock in the morning, and Mrs. Williams needed a CAT scan. I rolled her stretcher into the radiology department, where a burly technician and I tried to put her onto a table. But there was a problem: Her intravenous tubing wasn't long enough. The technician asked me if we could stop the IV drip she was receiving. "Sure," I replied automatically. I was mind-crushingly tired. As a new medical intern, I'd been working for 21 hours straight, with hardly time even for a toilet break. I wasn't really thinking about what was going on.
Midway through the scan, Mrs. Williams started moaning that she was having chest pain. When the scan was finished, I quickly reconnected the IV line and turned the machine back on, but all I got were beeps and flashing red lights. Then it hit me square in the gut: I had stopped Mrs. Williams' nitroglycerin, used to treat angina. She was having a heart attack.
Across the nation at noon today, fourth-year medical students will receive a piece of paper telling them where they will be spending the next 3 to 7 years of their lives training to become doctors. During this period, called residency, they will work 80 hours per week and stay up every fourth night or so on call — all while managing complicated patients like Mrs. Williams with little supervision.
Though they probably don't know it, they will also be entering a controversial debate about how many hours they should work. In December, a panel of educators convened by the prestigious Institute of Medicine recommended a mandatory 5-hour nap time for residents on call, as well as shifts no longer than 16 hours. This sounds like a good thing — for doctors themselves and especially for their patients. But work limits come with their own set of vexing problems — problems that could actually be worse than an epidemic of tired doctors.
You see, in response to work limits, teaching hospitals have been forced to increase cross-coverage — in a nutshell, caring for patients when their primary resident is not on duty. Most have created the position of "night float" — residents who work the night shift so others can sleep. The problem is that this system necessitates frequent patient handoffs, which can result in the transfer of faulty or inadequate information.
I'll never forget a patient I once took care of on night float who had esophageal cancer — and also intractable hiccups. A nurse mentioned a drug called chlorpromazine that was sometimes used to treat hiccups, so I wrote an order for it. Walking through the nurses' station, I casually checked the patient's chart. There, amid his papers, was a brief note. He had once suffered a severe reaction to this particular drug. It wasn't documented as an allergy on my sign-out sheet; I had been extremely lucky to stumble across it.
In medicine, as in aviation, most errors occur at transitions: by pilots, during takeoff and landing, and by doctors, after handoffs. Because of work limits, during an average monthlong rotation, an intern might be involved in more than 300 handoffs, which are susceptible to breakdowns in communication, thus potentially creating errors. Work limits have other troubling consequences as well, including interruption of resident learning and the creation of a kind of shift-work, clock-watching mentality among young doctors.
It is possible, in short, that work limits are weakening medicine more than exhausted interns ever did. I worry that, thanks to work limits, the current crop of interns is missing out on valuable lessons. As for patients, they are probably no better off — and maybe even worse.
Mrs. Williams, by the way, turned out just fine. She wasn't having a heart attack, and my fatigue-induced error was quickly corrected by a nurse. Of course, I don't deny that a doctor who has gone too long without sleep can make a grave error. But it is possible to overcorrect for even the most serious of problems. And in trying to get young doctors a bit more rest, we may have come up with a cure that is worse than the disease.
Sandeep Jauhar, M.D., Ph.D., is the author of Intern: A Doctor's Initiation, and the director of the Heart Failure Program at Long Island Jewish Medical Center. He writes regularly for The New York Times and The New England Journal of Medicine.