Work Rules Fail to End Danger from Tired Doctors
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National guidelines adopted three years ago say that hospitals must limit the hours that their interns and residents spend on the job. But the authors of a new Harvard study say those limits don't stop exhausted young doctors from making serious mistakes.
NPR's Richard Knox has the story.
RICHARD KNOX: The researchers asked 2,700 hospital interns to record the hours they actually worked. The study began before the new limits went into effect, but most study participants worked within the 80-hour a week limit prescribed by the guidelines.
Participants also reported their medical mistakes anonymously. Researchers counted the mistakes during months when interns had round-the-clock shifts. The guidelines allowed two such shifts a week.
Dr. Charles Czeisler says they compared heavy-duty months to those with no round-the-clock shifts.
Dr. CHARLES CZEISLER (Sleep Expert, Brigham and Women's Hospital): What we found was that when interns work these marathon 30-hour shifts, their risk of injuring a patient is increased by about 700 percent.
KNOX: The likelihood of a fatal error was more than three times higher during months with marathon shifts.
Dr. CZEISLER: Given that there are 100,000 medical residents nationwide, our data suggest that fatigue contributes to thousands of preventable deaths of hospital patients.
KNOX: The study asked the interns to be truthful in reporting work hours, mistakes and the times when they literally fell asleep on the job. But researchers checked on that honesty. They monitored the work hours of some. Others wore devices that recorded brain waves and muscle activity.
Dr. CZEISLER: They were the same devices that we developed for use on the NASA astronauts when we recorded the sleep of the astronauts in space.
KNOX: These checks showed that interns were actually under-reporting their hours and the times when they nodded off. Some even fell asleep during surgery or when examining a patient.
Dr. CZEISLER: We had one participant who reported that while he was doing a cardiac exam on a patient and he was listening to her heart with a stethoscope, he fell asleep and fell onto the chest of the patient. She was not happy.
KNOX: Czeisler is a sleep expert at Brigham and Women's Hospital in Boston. He says the new data dovetailed with lots of other research showing the human brain doesn't perform well when it doesn't get enough sleep everyday.
Dr. Stan Ashley says this is hard to argue with. He runs Brigham and Women's Surgical Training Program.
Dr. STAN ASHLEY (Surgical Training Program, Brigham and Women's Hospital): If you've worked 24 hours, you might make a few more errors.
KNOX: Because of Czeisler's data, the program has limited surgical trainees to 12 hours a day - one of very few programs to go that far.
Dr. ASHLEY: We have virtually no 24-hour shifts now. Occasionally, on a weekend, we will and we provide the residents cab fare to go home if they're here for a whole 24-hour period.
KNOX: So they don't fall asleep at the wheel.
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KNOX: But the Brigham's non-surgical trainees don't have those limits. Michael Westerhaus(ph), an intern, says his 80-hour weeks often include 20-hour stints followed by very little sleep before launching into another day of work.
Mr. MICHAEL WESTERHAUS (Intern, Brigham and Women's Hospital): The adrenaline kicks in, but you do always sort of feel that behind your eyes, sort of - that tiredness and awareness that you've only have two or three hours to sleep the night before.
KNOX: Brigham interns don't always get the 10 hours off prescribed by the national guidelines.
Mr. WESTERHAUS: I think having 10 hours off a shift would make a major difference in terms of sort of helping with the fatigue, the lack of concentration that happens on a post-call day.
KNOX: But limiting resident's hours is a hot topic. You just have to cross the street to another Harvard teaching hospital to find a dissenter. Dr. Joseph Fisher is chief of surgery at Beth Israel Deaconess Hospital and chairman of the American College of Surgeons Board of Regents. He says further cuts in work hours would be a mistake.
Dr. JOSEPH FISHER (Chief of Surgery, Beth Israel Deaconess Hospital): It's not good for patients.
KNOX: He says patients are better off with a tired doctor who knows their case than a fresh doctor who doesn't. And Fisher doesn't buy the idea that the amount of sleep really matters.
Dr. FISHER: Nobody really knows what the effect of the catnap is. How long does it take to restore the ability to do these tasks and get back to their rate, which is statistically insignificant?
KNOX: Fisher says his hospital is studying the catnap hypothesis.
Richard Knox, NPR News, Boston.
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