The New Health Dialogue

One in eight doctors is in training. And he or she is probably sleepy. That has consequences for patient safety and care.

Thousands upon thousands of newly-minted doctors, diplomas fresh in hand, ready to tackle the complex and often perverse world of health care.  Their fresh white coats won’t last long, and while many conditions around training have improved (the name “intern” arose because they lived in the hospital and were not paid at all for their services), some things haven’t changed. Like sleep, for example. Doctors just don’t. Doesn’t matter where you live, what kind of practice you are in, we just don’t sleep. And we know that has consequences for patient care and safety -- residency is notorious for stretching the limits. It was not unusual for me to be up all night every other night on trauma surgery rotations, or for more than 36 hours at a stretch in the intensive care unit. 

I remember one night, it was about 10:30 pm, when I had just finished a grueling “night” of call (it was really about 40 straight hours, starting at 6 am the previous day) in the cardiac intensive care unit. I was driving the 2.4 miles from the hospital to my house. I feel asleep at a stoplight. I was so deeply and peacefully asleep that it took a tap on the window from the driver behind me who had been honking to kickstart me into alertness. 

That was then. In 2003, the ACGME  set limits on resident work hours that forced programs around the country to rethink the way doctors like me were trained. The council put forward a set of what were then considered ambitious suggestions to ensure that residents did not work more than 80 hours a week (on average).

Well, that worked to some extent. But the issues did not go away, they merely took on a different form. Residents would simply claim they were working fewer hours than they actually did. When they did, in fact, work fewer hours, problems arose with “handoffs” -- which is essentially the way clinicians communicate patient cases to each other as they start or end work.  A handoff goes something like this:

Intern A:

Mrs. X is a 45 year old female with one month of progressive lower extremity edema of unknown etiology who presented to the ER last nite with acute shortness of breath. Chest x-ray is normal, d-dimer test negative and all cardiac enzymes normal. We still need to do a thorough metabolic and renal workup so you might want to order some of that now. Otherwise, she is comfortable on 2 liters of nasal cannula. I am thinking this is more cardiac so you might want to get a (cardiac) echo. Her other meds are pretty standard and we are giving her Lasix to dry her out a bit. She is a full code.

Intern B:

Ok, so what are her I’s and O’s (input and output) for the night and how much of a workup for heart failure have you started?

That may seem like little to no information, but these are the essential nuggets that get transmitted as hospitals try to balance clinical care and their educational mission. Now the ACGME is going to modify the rules again, mostly in response to a study by the Institute of Medicine (Resident Duty Hours: Enhancing Sleep, Supervision and Safety Recommendations) but will ask residency programs to use the following parameters:

• Duty hours will remain at 80 hours per week (averaged over 4 weeks)
• Scheduled continuous duty periods must not exceed 16 hours unless a 5 hour uninterrupted continuous sleep period is provided between 10 pm and 8 am
• Residents should not admit new patients after 16 hours during an extended duty period.
• Mechanisms should be put in place for residents to have an optional ride home after 16 hours of work

The ACGME is addressing some of the problems that arose after the 2003 requirements -- including few penalties and little accountability. This time, the ACGME will hold the institution, not the residency program, responsible, so hospital leaders beware. The safety of our patients depends on making these changes successfully while preserving the educational mission of the institution. In 2006, the Harvard Work Hours, Health and Safety Group reported that one in five resident-physicians admitted making a fatigue-related mistake that injured a patient. One in 20 admitted a fatigue-related mistake that resulted in a patient’s death.

As health reform moves forward, we must acknowledge the very real challenges that face our health care system. Acknowledge them. Not sleep through them.