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Working In These Times

Thursday, Sep 2, 2010, 11:21 am

Coalition Calls on OSHA to Regulate Medical Residents’ Work Hours

BY Lindsay Beyerstein

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Lack of sleep causes medical errors to skyrocket

Sleep deprivation is a silent public health threat, especially for medical residents. Pulling an all-nighter reduces your judgement and reflexes to the level of somone who is legally drunk.

Forty years of psychological research proves that sleep deprivation saps our mental faculties, including our ability to notice that we're impaired. It may come to feel normal, but the effects don't go away. That's bad enough for the average person trying to juggle work, family, and a social life. But consider the implications for medical residents who are responsible for patients' lives.

The Institute of Medicine, a branch of the National Academies of Science, undertook a year-long study at the behest of Congress to assess the impact of sleep deprivation on medical trainees. The 2008 report recommended that shifts be capped at 16 hours for the safety of residents and their patients.

Yet, new proposed guidelines for medical residents would allow most doctors in training to work shifts of up to 28 hours (24 hours, plus an additional hand-off period of up to 4 hours). Shifts for first-year residents (aka interns) would be capped at 16 hours.

A coalition of resident- and patient-advocates has decided that enough is enough. They want OSHA to take control of work standards for medical residents. Currently, the standards are set by a non-profit organization known as the Accreditation Council for Graduate Medical Education (ACGME).

The coalition includes the Committee of Interns and Residents/SEIU Healthcare, the American Medical Student Association, Public Citizen, and two prominent professors of sleep medicine. They are circulating a petition urging OSHA to set and enforce standards for interns and residents.

Sleep deprivation makes medical error rates skyrocket. One study found that interns made 36% more serious errors in the intensive care unit when they worked the traditional schedule of 30-hour stints every other shift than they did when their shifts were capped at 16 hours.

Sleepy residents are also more likely to hurt themselvses. Needlestick injuries are 73% more likely after 20 hours on the job than during shifts of 12 hours or less. Another study found that residents were more than twice as likely to crash their cars driving home after a 24-hour shift than after a shorter work day. Long-term sleep deprivation increases the risk of obesity, depression, and other chronic problems.

The coalition wants OSHA to cap shifts at 16 hours for all residents, not just for interns. Their petition also calls for at least one 24-hour day off per week and and least one 48-hour break per month. The group also wants stronger whistleblower protections, tougher record-keeping requirements, and stiffer penalties for residency programs that break the rules.

These changes could be expensive and logistically challenging to implement. To put it bluntly teaching hospitals lean heavily on residents as a source of cheap labor. Defenders of the old system argue that residents need to be on hand for long periods of time to watch the natural evolution of diseases in real time. Another argument against reducing work hours is that shorter shifts mean that patients will get handed off from one resident to another more often. Handoffs are risky because there's always the chance of an ommission or miscommunication.

These are legitimate concerns. However, it's hard to imagine that any of these factors outweigh the costs of letting sleep-deprived residents make life and death decisions after sleep deprivation has reduced key cognitive capacities to the level of a drunk.

The federal government already regulates work and rest hours in the nuclear industry, trucking, and other sectors where worker fatigue could endanger the public.

Troublingly, some new language in ACGME's proposed guidelines appears to acknowledge the dangers of sleep deprivation while shifting the responsibility to individual residents for monitoring their own fatigue levels.

The old section on professionalism and personal responsibility exhorted residents to behave ethically, put patients first, and embrace diversity. The new professional responsibility section says that "residents must take personal responsibility" for "assurance of their fitness for duty" and "recognition of impairment, for example illness and fatigue, in self and peers."

Self-awareness is important. But ACGME's language doesn't acknowledge the pressure that residents face from their supervisors and peers to push through fatigue. The language ignores the power imbalance between doctors in training and their superiors. In a culture where fatigue is equivalent to failure, admitting that you're too tired can have serious professional consequences. The demand that each resident monitor herself and bow out if she's too tired seems unrealistic in light of evidence that sleep deprivation blinds people to their own impairment.

If a sleep-deprived resident makes a mistake, this language would make it easier to blame her for failing to recognize her own fatigue, rather than faulting a system that expects trainees to work under unsafe conditions.



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