When Doctors Don't Sleep Three years after hospitals were told to limit the hours of young doctors, a new study says they're still exhausted. Join us for a discussion on sleep and patient care.
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When Doctors Don't Sleep

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When Doctors Don't Sleep

When Doctors Don't Sleep

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This is TALK OF THE NATION. I'm Lynn Neary in Washington. Neal Conan is away. You've been up since yesterday morning. You've already written endless progress notes, attended two lectures, seen over 15 patients, and you've still got three hours of your shift left. It's all part of a typical marathon schedule for a medical intern or a resident.

Long hours on the hospital ward have long been a part of medical training. But according to a new study by sleep specialists, when residents work a shift of 24 hours or more, they were three times more likely to make a significant medical error. After five 30-hours shift in one month, the chance of making a mistake increased by 700 percent.

We'll be speaking to the study's author a little later in the show, and a former medical resident who says working for 27 hours straight didn't affect her ability to care for her patients.

And later in the hour, the Political Junkie is back. If you have questions for Ken Rudin about the latest political news, you can e-mail us now at talk@npr.org.

But first, doctors and sleep. And we'd like to hear from you, especially the doctors in our audience. If you're a young resident, how many hours do you work each week, and just how exhausted are you? We'd also like to hear from patients. If you feel your care has been compromised because your doctor was too tired, give us a call. 800-989-8255 is the number here in Washington. Our e-mail address is talk@npr.org.

And first, we're joined by Jenny Blair, an M.D. at the University of Chicago who was in her third and final year of residency - she is in her third and final year of residency in emergency medicine, so she is well acquainted with the routine we've described. And she thinks no one should have to work such long hours. Thanks so much for being with us, Dr. Blair.

Dr. JENNY BLAIR (M.D., University of Chicago, Third-year Resident in Emergency Medicine): Thank you. It's good to be here.

NEARY: I wonder if you first can give us a sense of what a typical shift is like, one of these very long, 30-hour shifts?

Dr. BLAIR: Well, sure. You wake up very early in the morning, typically 4:30 or 5:00, drive to work, see your patients. They all need notes written on them, and then you round with the other physicians in your team. The day is spent doing various patient-care tasks, and then in the afternoon, the other physicians sign their patients over to you. You will be watching them overnight.

You will also see new patients all night as they come in through the emergency room - brand-new patients, sometimes 4, 5 a.m. You're lucky to get an hour or a few hours of sleep. You may get no sleep at all. And then the following day, the routine starts again. In theory, you should leave by noon. In practice, that doesn't always happen because various things come up.

NEARY: Now, you've written about this, and in the article that you wrote, you said sleep deprivation is not a benign condition, although the medical profession doesn't seem to agree with that. But why do you say that?

Dr. BLAIR: Well, I think it's intuitively clear to anyone who's been up for a long time that you just aren't on your game when you've very tired. And the longer that goes on, I think the more that's the case. The middle of the night, when you're suddenly faced with a desperate situation or even a routine decision, you just aren't as quick on your feet. You aren't thinking as clearly, your attention is less. You're drowsier. None of those conditions is conducive to optimal medical care.

NEARY: So how would it affect your judgment as a doctor? I mean, specifically, what kinds of mistakes might get made?

Dr. BLAIR: Well, I have friends who have written down the wrong drugs, the wrong doses. It's very common to be awakened by a page during the one or two hours of sleep you've been able to get and be confused about what's happening and where you are. And that's happened to me, certainly. It's taken me a long time to collect my thoughts.

It's harder to pay attention to the big picture of what's facing you. It's just - it's harder to think.

NEARY: Yeah. And have you ever really felt that you made - when you were in a situation like this, did you acknowledge the mistakes that you made, or…

Dr. BLAIR: I can remember a thousand small mistakes. I imagine there are probably many more serious ones that I wasn't even aware of. Dr. Czeisler's study alluded to the fact that residents under-report their errors, even if they think they know how many they've made. So I've probably made a great many, but I do remember being completely confused when I was paged in the middle of the night and taking a long time to collect my thoughts.

NEARY: Yeah. Is this a situation where residents on call are really set up to fail?

Dr. BLAIR: I think they are. I think that you're just playing with fire, asking people who have not had any sleep in 24 hours to make important decisions. I think that that is bordering on hubris to think that we're exempt from the normal human response to being tired, which is to fall asleep and to do poorly.

NEARY: Now there are rules about how long residents and interns can work, aren't there?

Dr. BLAIR: There are, indeed. And those were put into place several years ago by the accreditation commission for hospital residencies, and that was a considerable improvement on the previous situation, which was basically - the sky was the limit.

Eighty hours a week now, averaged over two weeks is the upper limit of total hours, and shifts can last no longer than 30 hours, and no more of nine of those a month. So that's better than…

NEARY: Now, are those strictly enforced, or…

Dr. BLAIR: Well, I - that's a good question. I think there's been studies done that show - at least in the first year that these rules were put into place -that something like 80 percent of interns were still exceeding those work hours. I imagine the situation is better now, but there's a very strong disincentive to report your own program as a resident.

NEARY: Yeah. Well, although of course these long hours and overnight shifts are considered a rite of passage for young doctors, there has been more and more research into the effect that these hours can have on their performance.

We're going to bring in Dr. Charles Czeisler now. He is one of the authors of this recent study we've referred to. He is Baldino professor of sleep medicine at Harvard Medical School and Brigham and Women's Hospital, and joins us now from a study at WGBH in Boston. Thanks for being with us, Dr. Czeisler.

Dr. CHARLES CZEISLER (Director, Division of Sleep Medicine, Harvard Medical School and Brigham and Women's Hospital): Thank you, Lynn.

NEARY: Can you tell us a little bit about how you conducted this study?

Dr. CZEISLER: The way we conducted this study was to track interns all across the United States in all different specialties by having them complete monthly survey questionnaires in which we recorded the number of hours that they worked, as well as the timing of when they slept and woke.

And we also recorded many other aspects of - and we asked many other questions about their weight and whether they had gained weight, whether they had lapses of attention, whether they had made mistakes that were related to fatigue or made mistakes that were not related to fatigue. And, in particular - among the 60 or 70 questions that we asked each month - we asked whether there were preventable patient injuries that had happened, including injuries that might have caused the death of a patient.

NEARY: Yeah. And is this the first time that there's been this kind of research specifically into this question of mistakes made? Because I know people have been looking at this question of the hours that doctors work for a while. But is this the first time that they've looked that specifically at errors as a result?

Dr. CZEISLER: Well, two years ago we did a study in which we had physicians monitoring physicians working in the intensive care unit around the clock, 24 hours a day, seven days a week. And we compared interns who were scheduled to work these traditional 30-hour shifts with interns who worked no more than 16 consecutive hours.

And in that study, we found that when the interns worked these 30-hour shifts, they made 36 percent more serious medical errors - including 464 percent more serious diagnostic mistakes - when they cared for patients for these traditional 30 consecutive hours, as compared to the shorter 16-hour shifts.

And in that study, we were asking the question whether it was better to have a fresh doctor take over for an intern at the end of their usual 16-hour day, or whether it was better to have the same doctor work all day and then continue all night. The traditional 30-hour shift is based on the notion that it's better to have a tired doctor who started with you that day than to have a fresh doctor. But we found actually that the tired doctors made many more mistakes.

NEARY: And what kind of mistakes are we talking about? How critical are these mistakes?

Dr. CZEISLER: These mistakes were typically slips and lapses. The team -including the faculty and the interns and the residents and the other more advanced residents - round on the patients every morning in an intensive care unit and make a plan for all the things that should happen to all the patients on that unit for the rest of the day.

And typically, then, we found that the interns who were going to be staying for the next 30 hours would have 1 or 200 tasks that they needed to do over the course of that extended-duration shift. And when they attempted to do those tasks - even if they got 95 or 97 percent of them correct - we found that when they were tired they tended to forget.

They had slips and lapses. They would either forget to do a complete exam on the patient and leave out important steps and then miss physical findings that were critical to the diagnosis of the patient, or they would forget to check up on a lab or they would forget to order a lab that the team had decided needed to be ordered. And depending on the gravity of the illness of the patient, these kinds of mistakes - ordering 10 times the dose of a medication or giving a medication to which the patient was allergic even though it was written on the chart that they were allergic.

These are the kinds of mistakes - sometimes attempting to do a procedure on the wrong side of the body of the patient only to be either caught - and most of the mistakes were actually caught by the safety net.

The nurses caught the lion's share of the mistakes, and sometimes other interns or residents would catch the mistakes. But many of the mistakes got through and reached the patient. And in that smaller observational study, we couldn't tell whether there weren't enough errors that harmed patients in that small group of setting - that smaller group of about a couple of dozen interns. We couldn't tell whether statistically, on a nationwide basis, we would be able to see whether the risk of creating harm to a patient would increase. So we needed to carry out this larger, nationwide study in which we studied thousands of interns from across the country.

NEARY: Dr. Blair - Jenny Blair - you are in your final year of residency in emergency medicine. And I'm just curious - before we have to go to a break -briefly, what's the conversation among residents and among those that are working these shifts right now? Are they - what's your sense of what young doctors feel about this?

Dr. BLAIR: That's a very good question. I think it's divided into several groups of people. There are the type of people that really feel that they can handle this and they're okay. And at 24 hours, maybe they're a little tired. And at 30 hours, they're definitely tired, but they feel fine and they think they're doing a good job. And I think those people probably just don't need very much sleep. But I still have a hard time believing that they're exempt from any performance degradation that Dr. Czeisler's describing.

Then there's the group of people who really resent it and are absolutely miserable and exhausted by 11:00 p.m., and are even more miserable and more exhausted by 3:00 or 4:00 a.m. and just detest call and detest the system. And we all thought it out, because that's what you do. There's just - there's really no alternative.

NEARY: All right. Well, thanks so much favor joining us today, Dr. Blair.

Dr. BLAIR: Thank you.

NEARY: Jenny Blair is a doctor at the University of Chicago, and she's in her third and final year of residency in emergency medicine. Dr. Charles Czeisler is staying with us as we continue our conversation about the effect of lack of sleep on doctors. It's TALK OF THE NATION from NPR News.

(Soundbite of music)

NEARY: This is TALK OF THE NATION. I'm Lynn Neary in Washington. We're talking about a new study that looked at the amount of sleep young doctors get. The results indicate that the chances of making a mistake skyrocket after a number of 30-hour shifts. In a few minutes, we'll talk with a medical resident who disagrees that that's a problem. Right now, our guest is Dr. Charles Czeisler. He's director at the Division of Sleep Medicine at the Harvard Medicine School and Brigham and Women's Hospital.

You're invited to join the discussion, especially the doctors in our audience. If you're a young resident, how many hours do you work each week, and just how exhausted are you? We'd also like to hear from patients. If you feel your care has been compromised because your doctor was too tired, give us a call at 800-989-TALK. And our e-mail address is talk@npr.org. And we're going to take a call now from Scott, and he is in Cincinnati, Ohio. Hi, Scott. You there, Scott?

SCOTT (Caller): Hello. Yes, I am.

NEARY: Hi, go ahead.

SCOTT: I attended a few years ago at the Grand Rounds at the University of Cincinnati Hospital. A presentation by a doctor who worked on a cardiac unit in the northeast - and I apologize for not remembering his name or his hospital -where he was interested in implementing Six Sigma, which is a manufacturing process that reduces the number of defects. And he cited the study that talked about the number of preventable errors that are committed in hospitals, and I seem to remember the number was in the hundreds of thousands.

He likened it to that if it were a manufacturing line that they would shut it down because of the number of defects. And it seems to me that the link between how tired people are and the types of mistakes that he was talking about - such as your guest mentioned, operating on the wrong part of the body and things like that - has to be in some way linked. And if people are going to deny that, I can't imagine that they have a leg to stand on.

NEARY: All right, Scott. Dr. Czeisler?

Dr. CZEISLER: Yes, well the Institute of Medicine did a landmark study in which they estimated that there are 98,000 deaths annually in the United States that are due to medical errors of one sort of another. We were very surprised in this study to learn how frequently the interns were admitting making serious fatigue-related mistakes that actually harmed patients. In fact, we found that over the course of a year, one out of five interns reported that they had made a significant medical error due to fatigue that had harmed a patient. And one out of 20 interns had made a significant mistake that had caused the death of a patient due to fatigue.

And to put this into context, there are 25,000 interns in the United States, and another 75,000 residents in the United States who are subject to these same punishing schedules where they work two 30-hour shifts every week. And, of course, we don't know if the same rate of errors that result in patient injury and death occur in residents who are further along in the process - although most of these, as I said, were errors of slips and lapses and not knowledge-based errors.

But if the rates are occurring in all of these residents at the same rate, that would mean that tens of thousands of preventable injuries are occurring to patients every year due to fatigue, and that thousands of preventable deaths are being caused by these exhausted doctors trying to function when the brain really is unable to perform reliably for 30 consecutive hours without sleep.

NEARY: Thanks for your call, Scott. Dr. Czeisler, this has long been a tradition - if that's the right way to put it - of the medical profession, it seems to me. What is the rationale?

Dr. CZEISLER: The tradition dates back to 1890 and was started by a pioneer in American medicine, Professor William Halsted from Johns Hopkins, who established the first program in residency training in surgery at Johns Hopkins and really set the standard for the nation. And he established these marathon 30-hour shifts. And it was only revealed this past year in an article in the New England Journal just how he was able to stay awake for so long. It turns out that he was a cocaine addict, and he had just been discharged from the Butler Hospital in Rhode Island where he had been an inpatient for, I think a year and a half, trying to get rid of his cocaine addiction.

They were using morphine to treat it, and so he ended up with a morphine and a cocaine addiction. As he took over his role starting that program, we're left with the same traditional schedule in which interns and residents are expected to go 24 or 30-hour shifts, and they're expected to perform at their best. Even our participants in this study reported not only nodding off and falling asleep while they were at lectures - which is, of course, understandable - but also when they were on rounds going from the bedside of one patient to the next, they reported nodding off and falling asleep. And they also did so while they were on their feet during surgery. In fact, that rate was increased by 160 percent of falling asleep during surgery when they were working these marathon shifts.

NEARY: And that would - let me just ask you this. They wouldn't be the only surgeon working on that patient at that time, would they? When you're saying they're falling asleep during surgery? Or would they be assisting in a surgery?

Dr. CZEISLER: Typically, there would be more than one surgeon present during an operation. And, of course, an intern would be unlikely to be carrying out a procedure themselves.

NEARY: Yeah, because that's frightening to hear that a doctor would be falling asleep during surgery. When you're under, you know, anesthesia and not aware of what's going on, that's really scary to think of.

Dr. CZEISLER: Well, 86 percent of Americans - in a nationwide poll that was done by the National Sleep Foundation - would be anxious if they knew that their surgeon had been awake for 24 hours prior to operating. And 70 percent would ask for a different doctor.

NEARY: Right. Actually, that seems like a low number to me, if you want to know the truth.

Dr. CZEISLER: And actually, we - State Senator Richard Moore here in Massachusetts has sponsored legislation that would require physicians to notify their patients if they had been awake for more than 22 of the previous 24 hours, because it is a question that the patients have a right to know if a doctor - we know that being awake for 24 consecutive hours impairs neurobehavioral functioning of the brain by an amount - if you measure it with reaction time - that is comparable to a blood alcohol level of .1 percent. So that would be legally drunk in virtually all states in the United States. So we - you know, you would expect to have a right to know if your doctor were legally drunk before operating. Certainly, you have a right to know if the doctor hasn't slept, because his performance impairment is comparable.

NEARY: Yeah, let's take a call now from Sara in San Francisco. Hi, Sara.

SARA (Caller): Hello?

NEARY: Go ahead, Sara.

SARA: Oh, thank you. I think my question was actually just answered. My husband is a surgical resident, and he comes home after his shifts and he struggles to stay awake at stop signs. I know people have had to honk their horns to wake him up. And, you know, my concern is actually for the patients. Anecdotally, when I tell people I know about how tired he is at work and about how tired he is when he comes home, they all express horror and say, you know, are my doctors that tired, too?

And so my question, actually, was just addressed, but I do think that patients should be told how tired their doctors are and should be required to give consent before operations or procedures from doctors who haven't slept. Thank you, I'll take my answer off the air.

NEARY: All right. Thanks so much, Sara.

Dr. CZEISLER: Well, it's interesting that Sara raises the point of her husband falling asleep at stop signs. And we did a study that was published this past year in the New England Journal in which we demonstrated that when doctors drive home from these marathon shifts, that their risk of having a motor-vehicle crash is increased 168 percent, and that their risk of having a near-miss crash where they run onto the rumble strip or into another line of traffic and so on is increased over 460 percent. So we know that it's a hazard for them to be driving home from these marathon shifts, and some hospitals have said well, the solution to that is just give them a taxi service when they're going home from the hospital.

But that, of course, begs the question of if they're that tired that they need a taxi to take them from the hospital, how can they in good conscious be given the responsibility and entrusted with the care of patients just before they leave?

NEARY: Well, we should say that not all residents feel that they or their patients suffer from working these very long shifts. Jennifer Linebarger is chief resident at Golisano Children's Hospital in Rochester, and she joins us now from a studio at WXII in Rochester. Thanks so much for being with us, Dr. Linebarger.

Dr. JENNIFER LINEBARGER (Chief Resident, Golisano Children's Hospital): Thank you.

NEARY: Now, you don't feel that - you didn't feel that when you had to work these kinds of very long shifts that it was a hardship or that it was bad for the patients, is that right?

Dr. LINEBARGER: That's right to a certain extent. What I believe is that I come from a program that has recognized the balance that needs to be obtained between the work hour regulations and one's ability to have continuity of care with the patients that they are intimately involved with.

And, thankfully, I live in the state of New York, who has had work-hour regulations in place five years longer than the national regulations have been in place, and who have stricter rules requiring us to not work more than 27 hours in a row and not allowing us to be involved in new patient care for the last three of those hours. And so there will never be a circumstance in which I am just starting to work up a patient, having not slept for 27 hours. By that point in time I will be back at home in my own bed.

NEARY: And how many of those 27-hour shifts might you work, let's say, in a week or in a month?

Dr. LINEBARGER: It works out for us. I actually looked at this before this afternoon's talk. And the average intern, who has more of these shifts than your other residents, does 24 weeks a year of taking this sort of 27-hour call every fourth day. Which means that over the half the year they're not on a schedule like this. They're able to go home and sleep in their own beds and be a bit more rested, which I think goes back to what Dr. Blair was saying.

Is that it's not that we're not exempt from the effects of fatigue, it's just if you can find a way to balance things so that it's not going on for long, extended periods of time, of months and months in a row of this sort of schedule, people can deal with it in a much healthier fashion.

NEARY: And as chief resident, you're creating work schedules now. Is that right?

Dr. LINEBARGER: That is correct.

NEARY: And so what guidelines do you use as you're doing that?

Dr. LINEBARGER: Well, we follow the ACGME requirements as well as…

NEARY: The ACGME is the Accreditation Council for Graduate Medical Education, right?

Dr. LINEBARGER: Precisely. We follow those as well as the New York State 405 regulations, which as I mentioned, are specific to us and a bit more strict than the national regulations. And so we recognize that every fourth day a resident is going to come in for a 27-hour call shift, much as was described by Dr. Blair.

We also know, though, that they leave by within 27 hours of walking in those doors. And because this is an environment that has been in place for eight years, nine years, at this point, faculty and staff and residents are all very diligent about making sure that they get out in a reasonable time.

The residents then have 18 hours completely free of patient care duties, even though the minimum requirement is only eight hours off. And I that that way they come back feeling a bit refreshed by the next day and ready to start the cycle again.

NEARY: We are talking about a new study on the affect of lack of sleep on doctors in hospitals. My guests are Jennifer Linebarger - she is the chief resident at Golisano Children's Hospital in Rochester - and Dr. Charles Czeisler. He is one of the chief authors of that study.

And you are listening to TALK OF THE NATION from NPR News.

We're going to take a call now from Jean, and Jean is in Iowa. Hi, Jean.

JEAN (Caller): Hi. I am a nurse who works in a trauma center. And my concern consistently has been of years of watching interns - because there's a medical school attached to the hospital I work in - exhausted interns and residents making both minor and major mistakes.

And the problem is, is that the burden for accurate medical care is falling on the nursing staff, to both catch the mistakes and to figure out ways to politely suggest to an exhausted resident that they need to rethink a decision that they just made. And it's very difficult for nurses to be in that position but it's something we have to do in order to provide accurate medical care. And I'm really interested to see what the physician from Rochester has to say about that.

NEARY: Dr. Linebarger?

Dr. LINEBARGER: Sure. I think that the benefit of the medical system is that there are lots of safety nets. Our system, as it currently stands, is a team of a senior resident who has been doing this for one or two years at least, as well as an intern. The intern usually makes the initial decisions and bounces those ideas and clears them by the senior resident, generally before acting on them or entering an order into a system in any way.

And then thankfully, just as the nurse mentioned - you know, nursing backup, pharmacy backup - all different systems are in place to make sure that patient errors don't actually get to a patient. I think the other benefit of that thing, with that teamwork approach, is that there was a very rare night that I didn't get at least half hour, hour-long catnap - where the nurses recognized I was getting tired, the senior resident might have recognized that I was getting tired - and allowed me to go lay down without paging me, you know, things that could wait.

And having that sort of environment made it safer and healthier for everybody.

NEARY: All right. Let's see if we can get in one more call here as we wrap this up. Victoria, in San Antonio, Texas.

VICTORIA (Caller): Hi there. Thanks for taking my call.

NEARY: Go ahead.

VICTORIA: I wanted to thank Dr. Czeisler for his research. I'm a physician that's just out of residency, and I wanted to make a comment on how sleep deprivation not only comprises your ability to be accurate but that also compromises your ability to be compassionate. Sleep deprivation makes you irritable, and mean, and less responsive to patients' needs.

And I think that a lot of people have negative experiences with the system partly because of the, you know, lack of compassion shown to residence.

NEARY: That's a very interesting point because a lot of people complain about the atmosphere in a hospital, when they're in the hospital. Dr. Czeisler, we've been talking about the mistakes that can be made as a result of sleep deprivation. But here's this issue of just not being very tolerant, as a result of being very tired.

Dr. CZEISLER: Well, that certainly is true. People become - well, there are, imaging studies of the brain have shown that the pre-frontal cortex and other critical areas of the brain that are responsible for judgment are impaired, and those impairments can be demonstrated with these imaging procedures when people are awake for 24 consecutive hours.

We also know - as this is probably due to changes in the brain - that people become much more irritable, and that there is increased liability in their mood. And these are the kinds of changes that that caller was just speaking about. We also know that when people make mistakes, that those mistakes can have consequences in terms - particularly if it results in the injury of a patient - in terms of a guilt, and feelings of frustration, and even depression can occur if a physician realizes that a fatigue-related mistake has resulted in the fatality of a patient.

NEARY: Dr. Czeisler, thanks so much for being with us today.

Dr. CZEISLER: Thank you.

NEARY: Dr. Czeisler is director at the Division of Sleep Medicine at the Harvard Medical School and Brigham and Women's Hospital. And thanks so much to Dr. Jennifer Linebarger for joining us today as well. Thank you, Dr. Linebarger.

Dr. LINEBARGER: Thank you.

NEARY: She is the chief resident at Golisano Children's Hospital in Rochester.

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