Forcing residents to nap may not improve patient care

Originally published in MedPage Today

by Emily P. Walker, MedPage Today Washington Correspondent

More that a year after the Institute of Medicine (IOM) issued a report calling for mandatory naps for medical residents, the organization responsible for implementing — or rejecting — the IOM’s controversial recommendation has yet to make a decision.

Forcing residents to nap may not improve patient care The Accreditation Council for Graduate Medical Education (ACGME), which has formed a work safety task force, has said it will release its recommendations on the 2008 report in the upcoming months, collect comments, and schedule a board of directors vote no sooner than fall.

In the meantime, the consumer advocacy group Public Citizen is trying to rally support behind adoption of the IOM report, which recommends, among other things, that residents take a five-hour nap for every 16 hour shift. Current standards allow residents to work for 30 hours straight.

The IOM report determined that standards adopted in 2003 — which mandated a maximum of 80 hours of work a week, when averaged over a four-week period, and no more than 30 hours straight — are not easing the problem of overworked and overtired resident physicians.

As part of its campaign, Public Citizen launched a Web site this week, www.wakeupdoctor.org, to promote safer work hours and more supervision for medical residents.

In a press call Thursday — led by Sidney Wolfe, MD, director of Health Programs for Public Citizen — physicians and patient advocates said that current work schedules of residents are dangerous and criticized ACGME for failing to have taken any action.

“Resident physicians find it very hard to concentrate as exhaustion sets in, especially when operating or evaluating patients beyond 16 hours in a single day on a regular basis,” said John Ingle, MD, an ear, nose, and throat surgery resident at the University of New Mexico Health Sciences Center in Albuquerque, N.M. “During times of extreme fatigue, I find myself less compassionate toward my patients and less tolerant of my colleagues.”

“My body is not made to work 30 hours or more,” said Dan Henderson, a third-year medical student at the University of Connecticut. “If I’m truly going to do no harm as I pledged, I need a system to protect patients against errors caused by my fatigue. If ACGME isn’t willing to do the right thing, hopefully consumers and lawmakers will be ready to step in.”

A sleep specialist went through a list of the dangers of sleep-deprivation in a medical setting:

“Resident physicians working 30-hour shifts make 36% more medical errors caring for women in the intensive care unit … including 460% more serious diagnostic mistakes than those scheduled to work for 16 hours,” said Chuck Czeisler, MD, of Harvard and Brigham and Women’s Hospital.

“They are 73% more likely to stab themselves with a scalpel or needle,” he said.

Czeisler cited a survey that found after a year of working “marathon shifts” one in five residents admitted to making a fatigue-related mistake that injured a patient, and one in 20 said they made a fatigue-related mistake that resulted in the death of a patient.

However, not everyone is sold on those statistics.

Perry Pugno, MD, a director of a family practice residency program for 20 years, asserted that no definitive study has proven that the 2003 guidelines aren’t working. He said most sleep studies are performed in a lab or in the transportation industry, and questions their applicability to the hospital setting.

Besides, he said, “Many people come to work in many industries sleep deprived. Restricting the hours of work doesn’t necessarily mean you’re going to get a well-rested person during the period you’re going to be working.”

He doubts that residents would be willing or able comply with the 2008 IOM recommendation that they take an uninterrupted nap for five hours between every 16 hour shift. It’s nearly impossible to take a nap in the middle of an intense work shift, said Pugno, who is now the director of the Division of Medical Education at the American Academy of Family Physicians.

As other critics of the IOM report point out, if more residents are forced to work shorter shifts, they will be handing off the care of their patients to another resident, physician, or nurse more often. And medical errors are more likely to occur when the care of the patient is transferred, Pugno said.

He recently co-authored a paper that presented results from a survey of 265 residency program directors that asked their opinions of the IOM recommendations. More than 60% disagreed or strongly disagreed with them.

The long hours serve to educate, Pugno said, and to help build intimate doctor-patient relationships that mandatory nap time would sever. He also said that most directors of residency programs are sympathetic to the sleep needs of their residents and schedule shifts accordingly.

Cost is also a major issue in implementing the IOM recommendations. In the 2008 report, the IOM authors estimated the changes they recommended — which also included greater supervision of residents and transportation home for bleary-eyed residents after a long shift — would cost $1.7 billion annually.

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