What Medical Students Should Know About Fatigue, Patient Safety and Resident Wellness

Dr. Thaddeus Lynn
CIR New York Regional Vice President

No question about it—becoming a doctor has always been arduous. It takes years of mentally and physically demanding training to learn the science and art of medicine. But a growing body of scientific evidence now points to the link between the extremely long hours that many resident physicians are required to work and an increased risk of preventable medical errors.

We’ve known for more than 25 years that long hours and inadequate supervision can be recipes for disaster. Libby Zion, an 18-year-old woman admitted to a New York City teaching hospital in 1984, died from a fatal drug interaction administered by overworked and unsupervised residents. The investigation of her death cast a public light on residency training and resulted in the enactment in 1989 of the first and only state regulations governing resident work hours and supervision.

Over the past twenty years, the scientific evidence on fatigue and medicine has continued to mount. One study published in 2006 in the Public Library of Science Medicine (PLoS-Medicine) found that interns working on-call shifts of 24 consecutive hours or more increased the incidence of preventable medical errors sevenfold and one out of 20 residents reported after their first year of residency making a fatigue-related error that led to a patient’s death.

Fatigued residents are also at greater risk of harming themselves. One study published in the New England Journal of Medicine found interns experienced more than twice the risk of a car crash after driving home after a shift of 24 hours or more compared to driving home after a regular shift.  Additionally, a study published in the Journal of the American Medical Association found a shift of 24 hours or more increased the risk residents faced of needle sticks and other accidental percutaneous injuries by 61 percent.  Medical students doing clinical rotations are also at increased risk of car crashes, needle stick injuries, and fatigue related medical errors!

This startling data caught the attention of Congress and resulted in a request for the Institute of Medicine (IOM) to investigate medical residents’ work hours. The 2009 IOM report, Resident Duty Hours: Enhancing Sleep, Supervision and Safety, recommended increased supervision of residents and a limit of no more than 16 consecutive-hour shifts. If a residency program wanted to continue scheduling residents for 30-hour shifts ( the present limit set by the Accreditation Council on Graduate Medical Education or ACGME), the IOM recommended a mandatory five hour rest period between the hours of 10 pm and 8 am.  The IOM also recommended doing away with the averaging of every third night on-call.   That averaging allows for resident physicians to be scheduled to work 30-hour shifts as frequently as every other night for a week or more so long as the average over four weeks is every third night. Often under these circumstances the resident physicians must attempt to perform his/her duties well with little or no sleep.

In September 2010, the ACGME released new work hour standards which will go into effect in July 2011. They acted on the IOM recommendation that shifts be limited to 16 continuous hours – but only for interns. All other resident physicians can still be scheduled to work 28-hour shifts and every third night call can still be averaged. Supervision requirements have been strengthened, but details about the enforcement of the new work hour limits are largely absent. The IOM had recommended that outside entities (the Joint Commission and the Centers for Medicare and Medicaid Services) monitor the work hour standards, but the ACGME rejected this change.

Medical students are our next generation of physicians. They should take heart despite organized medicine’s slow embracement of badly needed reform of residents’ work hours. Fortunately, significant change is on the horizon.  A growing number of innovative medical educators have begun to act on the scientific evidence linking long hours and increased preventable medical errors. Residency training redesign is happening — from the general surgery program in Portland, Maine to the internal medicine programs in New York City; Akron, Ohio and Seattle, Washington and the obstetric and gynecology programs in San Jose, California and Denver, Colorado. The results are safer patient care, improved training opportunities, and an increased emphasis on resident wellness.

Medical students can help support this innovation by seeking out these innovative programs and ranking them high on their Match Lists. You can find those cutting edge medical educators, as well as the latest news and scientific literature on fatigue and resident work hours at www.hourswatch.org. Surf this website and you will also find the results of a 2010 consumer opinion poll on the hours that resident physicians work as well as support for reform. Eighty-one percent of respondents believed patients should be informed if a treating resident physician had been working for greater than 24 hours and 80% would then want another physician to care for them.   In this era of “patient-centered care,” we would do well to heed our patients’ practical advice, follow the evidence and dedicate ourselves to providing safe, quality care.

References
1. Barger et al. “Impact of extended-duration shifts on medical errors, adverse events, and attentional failures.” Public Library of Science Medicine, Dec. 2006 3(12).
2. Barger LK et al. NEJM 2005; 352:125-134
3. Ayas, et al. “Extended Work Duration and the Risk of Self-reported Percutaneous Injuries in Interns.” JAMA, Sept. 6, 2006, 296(9)
4. Ulmer C, Wolman DM, Johns MM, eds. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: National Academies Pr; 2008.
5. US public opinion regarding proposed limits on resident physician work hours Alexander B Blum, Farbod Raiszadeh et al. BMC Medicine 2010.

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  1. This is a long awaited topic of rich discussion especially among medical students and future residents. I believe it is best for all that these discussions lead to effective improvements in the wellness of medical students and residents. Future physicians and physicians alike are so busy saving the lives of others they are literally killing themselves to do so. I predict with the recent healthcare reforms that there will be more patients and less physicians to care for them. This will create the potential for more fatigue and stress. Let’s do something about it before we reach this boiling point of epidemic proportions.