Flavio Casoy vividly remembers one of his scariest moments as an intern: On duty at a San Francisco hospital for nearly 29 hours, he was at the bedside of a very sick patient when the man’s oxygen level began to plummet. Casoy stared, transfixed, at the monitor. “I knew something was wrong, but I couldn’t make myself think,” he recalled. Only after “a colleague walked into the room, pushed me on the shoulder and said, ‘Get going’ ” did the exhausted doctor spring into action.
These days, interns, as first-year residents fresh out of medical school are known, no longer face the punishing shifts Casoy endured just four years ago. In July 2011, after more than two decades of impassioned debate, the Accreditation Council for Graduate Medical Education (ACGME) reduced the maximum allowable shift for the least experienced doctors from 30 straight hours to 16. That’s the point at which studies have found performance begins to deteriorate, and roughly double the consecutive hours of flying time allowed pilots. The council, which oversees residencies for 111,000 young doctors, also reaffirmed a controversial 2003 directive limiting the average workweek for all residents to 80 hours — the equivalent of two full-time jobs.
In mandating shorter shifts for interns, a move opposed by more than 70 percent of residency program directors, the ACGME cited studies linking fatigue to serious medical errors and injuries to residents from needle sticks and auto accidents. After their internship year, residents are permitted to work up to 28 hours per shift, on the theory — disputed by sleep researchers — that they learn to effectively manage fatigue. Depending on the specialty, residency training lasts an additional two to seven years.
But as a new class of interns, who arrived July 1, begins treating patients in teaching hospitals around the country, a recent spate of studies questions whether the rules have made the situation worse.
Medical researchers at Johns Hopkins University and the University of Michigan have found that shorter shifts have resulted in greater work compression, forcing interns to cram more work into fewer hours and depriving them of valuable education by limiting the time they can spend treating patients whose illnesses evolve. A March editorial in JAMA Internal Medicine decried the new standard as “too inflexible” and warned that shorter workdays are increasing handoffs, which can cause errors as patients are transferred from doctor to doctor.
“The 2011 rules have led to many unintended consequences,” said Sanjay Desai, director of the internal medicine residency at Johns Hopkins Hospital, adding that the 16-hour cap “was imposed without [sufficient] data showing it would be beneficial.”
Desai led a study that randomly assigned interns to the new system and compared them with interns who worked traditional hours. Under the 2011 regimen, interns got more sleep but attended fewer educational programs to avoid exceeding work hours; the 2011 group also said they believed they were delivering poorer care than interns who worked longer shifts.