Op-ed: Restrictions on physician hours may not improve patient safety

A version of this op-ed was published on June 2nd, 2010 in USA Today.

During medical training, I routinely stayed awake for more than 30 hours straight to care for my patients in the hospital. I strove to be the tireless physician who would be with his patients until they went home.  It turns out I may have jeopardized their safety instead.

For many years, the medical field has been rightfully concerned about doctor fatigue. Since 2003, medical interns and residents have been limited to 80-hour work weeks and 30-hour shifts. A year later, as if to put an exclamation point on the industry’s concerns, a New England Journal of Medicine study confirmed that doctors made substantially more medical errors when they worked frequent shifts of 24 hours or more.

The Institute of Medicine, an independent non-profit that provides authoritative advice on national health issues, subsequently recommended further limits in 2008, including capping continuous shifts at 16 hours and mandating naps during extended periods of work.  These controversial changes have yet to be implemented by the Accreditation Council for Graduate Medical Education, which sets the rules.

But if fatigued physicians are more prone to make errors, shouldn’t better-rested doctors make fewer mistakes?

Not necessarily.  A study released last month by the Cincinnati Children’s Hospital Medical Center found that further restricting doctor work hours in accordance with the IOM recommendations did not enhance sleep or improve patient safety. In fact, researchers found not only was sleep time unaffected, but physicians’ work-life balance actually worsened.

Shortened work shifts can carry potential risks, some of which were also pointed out by the IOM, but without specific recommendations on how to resolve the problem. Shorter worker shifts:

1. Result in more “patient handoffs” between doctors, which introduces a potential source of errors. A study released in March and led by Vineet Arora, assistant professor of medicine at the University of Chicago Medical Center, found that important clinical data, like patient drug information, was not communicated between the outgoing and incoming doctor 60% of the time. That’s alarming when you consider that patients are passed between doctors an average of 15 times during a typical five-day hospitalization. And when resident physicians at Boston’s Massachusetts General Hospital were surveyed in 2008, more than half said flawed handoffs resulted in patient harm, including prolonged hospitalization, disability or death.

As Dr. Arora points out, there are “concerns about either a tired physician who knows the patient or a well-rested physician that may not know the patient.”

2. Can hamper physician education. The field of surgery, for instance, requires manual dexterity and physical endurance that comes from time spent in the operating room. A British Medical Journal analysis found that a maximum 80-hour workweek did not provide surgeon trainees with the necessary technical mastery.

3. Present ethical dilemmas for doctors. What if a hospitalized patient becomes seriously ill at a time when a doctor is forced to leave because his time limit had been reached? A New England Journal of Medicine editorial said that arbitrarily restricting hours “will signify to our trainees that the overriding consideration is the duration of the shift.”

4. Increase costs. Implementing the IOM recommendations is estimated to cost $1.7 billion, as cash-strapped hospitals have to hire more staff to account for the decrease in physician working hours.  That may not be money well-spent for reforms with such questionable benefit.

Nuance is required to prevent the unintended consequences of work restrictions. Rather than forcing doctors to nap or go home at a defined time, flexibility is needed so physicians can temporarily stay during medical emergencies. During a crisis, patients will appreciate being cared for by a doctor who already knows them, rather than someone new.

And lessons can be learned from the aviation industry, which require pilots to maintain a “sterile cockpit,” prohibiting non-essential communication during takeoffs and landings. Similar focus should be required of physicians when patients are discussed during shift changes.

Failing to do so not only adversely affects how physicians are trained but makes doctors slaves to the clock, stifling the professionalism needed to properly treat patients. And that, ironically, may hurt patients more in the long run.