Safety of Medical Residents' Long Hours Questioned

Heather Brewster, pictured in 2002.

Heather Brewster, pictured in 2002. Courtesy of the Brewster family hide caption

itoggle caption Courtesy of the Brewster family
Simon Ahtaridis

Simon Ahtaridis, a second-year resident based in Cambridge, Mass., is regional president of the Committee for Interns and Residents. The group is working on state and federal efforts to reduce residents' work hours. hide caption

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Seven years ago, Heather Brewster's car was rear-ended by Sookim Hong, a medical resident who'd just finished a 36-hour hospital shift. Brewster suffered massive brain injuries and was in a coma for weeks. The accident left Brewster permanently disabled: she now walks slowly, doesn't remember much of what she used to and has been declared incompetent by the courts.

The Risks of Fatigue

Other researchers have explored risks associated with fatigue among medical interns. Among the findings:

· The impairment associated with 24 hours of sleep loss is comparable to that associated with a 0.10 percent blood alcohol concentration.

· The average reaction time triples when individuals are awake for 24 consecutive hours. The slowest 10 percent of reaction times increase in duration by nearly 10 times.

· Attentional failures occur frequently after being awake for 24 hours. These failures occurred twice as often at night among interns working 30-hour shifts, as compared to those same interns when they were scheduled to work no more than 16 consecutive hours.

· Interns working 30-hour shifts in an intensive care unit made 36 percent more serious medical errors, including 5.6 times more serious diagnostic errors, as compared to those same interns when they were scheduled to work no more than 16 consecutive hours.

Brewster's family is suing Hong and the hospital that employed her at the time. Some medical residents say the courts may be the only way to force a change in hospitals' long-held practice of working residents for long stretches at a time.

Report an Incident

The Harvard Work Hours, Health, and Safety Group continues to gather data on the association between medical interns' work hours, extended work shift, and driving safety. You can report an incident of motor vehicle crashes, near-miss accidents, needle stick accidents and medical errors on the group's Web site:

The lawsuit comes as new studies find that when doctors-in-training work long on-call shifts, they are more likely to cause motor vehicle accidents when they leave work.

The Science Behind Safety Concerns

Currently, medical residents' hours are set by the Accreditation Council of Graduate Medical Education. Two years ago, the organization reduced residents' on-call shifts to 30 hours maximum.

Dr. Laura Barger, Dr. Charles Czeisler and their colleagues from the division of sleep medicine at Brigham and Women's Hospital in Boston recently surveyed 2,700 first-year interns. They found that when interns worked long on-call shifts, they were more than twice as likely to get into car accidents after leaving the hospital.

The study was conducted in the 2002-2003 academic year, before the ACGME reduced residents' on-call shifts. Below are some highlights from the study.

Summary of Findings from the Harvard Work Hours, Health and Safety Group:

— Average number of consecutive hours worked by interns in 2002-2003 on extended-duration shifts: 32 consecutive hours*

— Average number of hours worked per week in 2002-2003: 70.7 hours**

— When interns drove home from an extended (longer than 24-hour) work shift, their odds of a motor vehicle crash were 2.3 times greater than when the same interns commuted from work after a shift that, on average, was less than 12 hours long. Interns' odds of a near-miss crash (in which bodily harm or property damage were narrowly avoided) were increased nearly six fold after an extended-duration work shift.

— In a prospective analysis during the 2002-2003 academic year, every extended work shift that was scheduled in a month increased the monthly risk of a motor vehicle crash during the commute from work by 16.2 percent. (The new ACGME regulations allow eight 30-hour shifts to be worked per month.)

— In months in which interns worked five or more extended shifts, their odds of falling asleep while driving were 2.39 times greater; their odds of falling asleep while stopped in traffic were 3.69 times greater than in months when they did not work extended shifts.

— Interns were awake 96 percent of their work time in U.S. hospitals during the 2002-2003 academic year. They reported that their patient workload did not allow them to make much use of the "on-call" rooms that hospitals provide for them to sleep.

* Note: In July 2003, ACGME regulations set the shift-duration limit at 30 consecutive hours, and permitted every other shift to be extended. On this new ACGME-sanctioned schedule, a 30-hour shift can alternate with an 10-hour shift in consecutive sequence, such that a typical seven-day work week under the new ACGME guidelines would be: Monday and Tuesday: 30-hour shift; Wednesday: 10-hour shift; Thursday-Friday: 30-hour shift; Saturday: 10-hour shift; Sunday: day off.

** In July 2003, ACGME regulations set the weekly work-hour limit at 80 hours, averaged over four weeks.

Research summary provided by Dr. Charles A. Czeisler, director of the Sleep Medicine Division at Harvard Medical School.

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