Christopher P. Landrigan is the research director of the Inpatient Pediatrics Service at Boston Children’s Hospital, director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital and an associate professor at Harvard Medical School. Charles A. Czeisler is director of the Sleep Health Institute and chief of the Division of Sleep and Circadian Disorders at Brigham and Women’s Hospital and a professor at Harvard Medical School.
While a handful of high-profile policy questions have preoccupied Americans since the election, one potentially catastrophic health-care change has quietly been taking shape without much media attention.
The Accreditation Council for Graduate Medical Education — the professional body charged with overseeing the nation’s physician training programs is poised to eliminate the 16-hour limit on work shifts for first-year resident physicians (referred to as interns) that it implemented in 2011. It proposes allowing interns to return to working extreme shifts of 28 hours — twice each week.
Sleep-deprived doctors cannot safely care for patients or themselves. An enormous body of science demonstrates that sleep deprivation impairs resident physicians’ performance as much as being legally drunk. Shifts of 24 or more consecutive hours lead to:
●A 36 percent increase in serious medical errors and 5.6 times as many diagnostic errors.
●An increase in fatigue-related errors resulting in eight times as many patient injuries and four times as many patient deaths.
●A 72 percent increase in resident doctors’ risk of accidentally sticking themselves with needles.
●And a 168 percent increase in the rate of young doctors’ car accidents while driving home from work.
After completing an intensive, year-long review of this issue in 2008, the Institute of Medicine concluded that it was unsafe for resident physicians to work for 16 consecutive hours without sleep. In response, the ACGME implemented a 16-hour consecutive limit only for first-year resident physicians. This action fell far short of the IOM’s recommendation that sleepless extreme shifts be eliminated for all resident physicians (residency programs last three to seven years), but it was a first small step in the right direction, substantiated by decades of evidence.
Now, the ACGME is set to reverse itself. With what apparent justification? Last year, a large — but seriously flawed — multi-center study reported no difference in mortality and major surgical complications between hospitals randomized to have 28-hour work shifts twice per week and hospitals with capped shifts at 16 hours.
Interns, however, have little influence over death and surgery. Detailed studies of surgical interns’ daily activities have shown that they spend only a small minority of their time in the operating room. When they do go in the OR, their roles are typically limited and tightly controlled. In reality, the performance of senior doctors is the main factor behind mortality and complication rates, and senior doctors’ work schedules were no different in the two arms of the trial. There were no intern-specific measures of patient safety (e.g., intern medication ordering errors). There was also no objective evaluation of the safety of the interns themselves.
Despite these flaws, those within the medical community opposing work-hour limits have latched onto this study and have pressured the ACGME to again allow the 28-hour shifts. They argue that handoffs of care between doctors at change of shift are unsafe and that shortening shifts — which results in more handoffs — could counterbalance any benefit of reducing fatigue. However, studies looking directly at this issue have found the 16-hour shift system to be much safer overall. While botched handoffs are an important source of medical error, the solution to poor handoffs is not to avoid them, but to improve them.
The scientific literature is clear that doctors’ sleep deprivation is dangerous. But this is also common sense: One survey found that 86 percent of Americans — across all regions, demographic groups and political affiliations — disapprove of the ACGME’s proposal to eliminate the 16-hour limit for interns. In fact, the public doesn’t believe senior resident physician should work for more than 16 hours either. Just as none of us would want our pilots to be flying for 28 hours straight, we don’t want our doctors to be impaired while writing medication orders, interpreting diagnostic tests or performing surgery on us or our loved ones.
Medical errors are a leading cause of death in the United States, and sleep deprivation among doctors is an important contributor to the problem. We are at the beginning of a long journey to improve the safety of health care in America. For the sake of our patients and our doctors in training, we should not revert to the dangerous work schedules of the past.
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