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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  • Intern from India

    Critics of the IOM report including Dr Pugno are just trying to scrape some publicity here. A 5 hours break after a 16 hour shift is like heaven! After that one can return to work totally refreshed and function so much better!
    People like Dr Pugno should go back to med school and try to learn some physiology.
    Honestly, the status quo as far as work hours are concerned, doctors like Dr Pugno and the policies that they propagate are serious threats to patient lives and to the integrity of the healthcare system as a whole. It’s a real shame.

  • Chris

    “Perry Pugno, MD,…most sleep studies are performed in a lab or in the transportation industry, and questions their applicability to the hospital setting”

    Is this guy for real???????

    Can anyone explain how evaluating a complicated patient in the ICU or performing surgery requires less mental acuity that driving a truck or flying a plane!!! The only difference I can see is that if a physician makes a mistake, only one person dies, if a pilot makes a mistake over 100 people die.

  • Doc99

    I knew docs who managed to sleepwalk through residency. Does that count?

  • William Hsu

    Few points:
    1) Errors in handoffs represent errors that can be improved upon (stick to rigid protocol about displaying the most important facts- kinda like the checklists used in pre-op, peri- op, post op transfers), while errors of fatigue only get worse as you lenghten shift hours
    2) there is a valid point in saying…. restricting work hours doesn’t necessarily result in more sleep. A resident can simply do other things aside from sleep. that doesn’t mean directors shouldn’t encourage an atmosphere where more sleep can be obtained
    3) the easiest way to insure 5 hour naps between 16 hours sleep is to have a room IN THE HOSPITAL dedicated to this purpose and REQUIRE residents to sleep there. We could call this room perhaps… the on call room. If only hospitals had this magical room. Oh wait they do- just mandate sleep there.
    4) I feel this is just another example of the medical profession being slow to adapt to new information and technology. As far as policy goes i’m pragmatic… i have no nostalgia on how residencies were done “back in the day”. Just because something was done a certain way in the past doesn’t mean we have to continue those traditions. Doctors should be progressives… we should always try to improve education styles and creating good doctors.
    5) I feel working through sleep deprivation is merely a badge of honor that some doctors like to carry. Sure there will be a time when doctors will be sleep deprived and will need to learn to push through fatigue. but this should be the exceptions not the norm of the profession. Personally i feel that the medical profession should encourage doctors to value sleep in order to raise productivity.

  • Necandum

    Just from personal experience, I’v found that taking a nap of a only a few hours after a period of sleep deprivation (more than, say, 20 hours awake) only makes it worse.

    Perhaps age has something to do with it, but I remember reading somewhere (sorry, can’t find) that when one group was kept awake for 36 hours with no sleep, they performed better than another group kept awake for 32 hours, then awoken an half hour or so before the test. I think it might have something to with interrupting some important sleep phase which leads to you being wacked you out.

    On the other, naps under an hour seem to help quite alot, so…

  • http://fertilityfile.com IVF-MD

    Naps are great, but leave the choice to the people who are doing the napping. How about just encouraging hospitals to provide a place so that residents have the OPTION?

    During residency, we worked as a team to allow each of us to get a nap. We didn’t need any regulatory board telling us to nap. It’s ludicrous to make napping MANDATORY. What’s next? Telling residents when to use the bathroom or when to eat milk and cookies?