By David Brown
Washington Post Staff Writer
Wednesday, December 3, 2008
Medical and surgical residents in hospitals should work no more than 16 hours without taking a mandatory five-hour sleep break, and they should get one full day off a week and at least two back-to-back days off a month, a panel of experts at the Institute of Medicine recommended yesterday.
The experts proposed work rules for physicians-in-training that are considerably more restrictive than those that went into effect in 2003 but are widely violated.
The panel also urged greater supervision of doctors in residencies, which last from three to seven years, depending on the specialty. Interns -- physicians in their first year of training after medical school -- should have supervisors who are in-house and not available just by phone.
"Our overarching conclusion is that the science clearly shows that fatigue increases the chances of errors, and residents often work long hours without rest and regular time off," said Michael M.E. Johns, a physician and the chancellor of Emory University who led the 17-member panel.
The 324-page document is the latest in a series of reports on ways to improve the quality and safety of American medicine. The Institute of Medicine, part of the National Academy of Sciences, provides expert advice to Congress.
The Accreditation Council for Graduate Medical Education, which oversees residency programs, currently sets the maximum workweek at 80 hours, with shifts to last no more than 30 hours. It also requires that residents get at least four days off per month, although there does not have to be one in each week.
A survey of about 4,000 interns found that in the first year those rules were in effect, 84 percent reported working shifts that violated them at least one month of the year. Forty-three percent reported working more than 80 hours weekly.
At Vanderbilt University Medical Center in 2005, 85 percent of medical and surgical residents reported violating the 30-hour shift limit.
While fatigue "clearly is a factor" in mistakes by physicians, the panel found it impossible "to assess the current level of all risks to patients or the degree to which fatigued residents contribute to patient harm."
Research shows that fatigue is also hazardous to the residents themselves, increasing the risk of car accidents and depression.
A study in 1996 found that pediatric residents, who slept on average less than three hours a night when they were on call, were twice as likely to be in car accidents as faculty members, who did not report sleep-deprived nights.
The panel, which included sleep researchers and quality-assurance experts, as well as physicians, acknowledged that there is a chance the new recommendations could make things worse. That is principally because an enforced sleep break after 16 hours will require more patient "handoffs" than occur now.
That transfer, which requires passing lots of information about ill patients to a receiving physician who has probably never seen or examined them, is a known source of medical error.
"We need to create a team approach to the management of patients," said David F. Dinges, a sleep researcher at the University of Pennsylvania. "We do not just assume that handoffs will remain a problem. We believe it is a fixable problem."