Talking About Resident Work Hours and Supervision

For decades, patient safety groups have been calling for measures to better protect patients from medical error. Now, advocates are turning their attention to the strong evidence linking the working conditions of sleep-deprived and/or under-supervised resident physicians and medical error.

On Feb. 4, 2010, a coalition of organizations led by Public Citizen, Mothers Against Medical Errors and other patient advocates sent a letter to the head of The Accreditation Council for Graduate Medical Education (ACGME) calling for shorter shifts and more supervision of resident physicians in an effort to boost patient safety.More than 40 health care, patient safety and other public interest advocates signed the letter, which was timed to coincide with a meeting by the ACGME.

The groups also launched aWeb site, www.WakeUpDoctor.org, to solicit additional signatures and collect stories of patients who may have been harmed by the current system. Since its launch, over 650 individuals have signed the petition.

The letter was copied to Rep.Henry Waxman, chair of the House Energy and Commerce Committee, the legislative body that had originally requested a study of resident physician fatigue and medical errors that culminated in the 2008 report by the Institute of Medicine, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. In a telephone news conference, activists, sleep experts, medical students, and resident physicians spoke about the dangers posed by residents working 30-hour shifts and urged the ACGME to act on the recommendations from the IOM report.

“Few, if any, people would fly on a plane whose pilot had been awake and working for 25 to 30 hours. Federal regulations prohibit pilots from flying more than 30 to 35 hours a week,” said Dr. Sidney Wolfe, director of Public Citizen’s Health Research Group. “But because medical residents work on shifts lasting as long as 30 hours straight, they become fatigued, making them more susceptible to making errors that greatly harm patients. It is likely that there are more deaths in U.S. hospitals each year caused by sleep-deprived doctors than the total annual deaths from plane crashes and train accidents.”

The scientific evidence linking acute and chronic sleep deprivation with preventable medical errors has mounted steadily over the years, Wolfe said. “Reducing the length of their shifts is the commonsense approach that both the medical field and consumers need.”

“After 24 hours without sleep, attentional failures at night double and impairment of reaction time is comparable to the impairment induced by drinking alcohol,” said Dr. Chuck Czeisler, a professor and director of sleep medicine divisions at Harvard Medical School and Brigham and Women’s Hospital. “The clinical performance of physicians—who are used to being at the top of the class—drops to the seventh percentile of their rested performance. Yet, as with alcohol, those affected by sleep loss often do not recognize their impairment.”

In 2006, the Harvard Work Hours,Health and Safety Group at Brigham and Women’s Hospital in Boston reported that one in five first-year resident physicians admitted making a fatigue-related mistake that injured a patient. One in 20 admitted a fatigue-related mistake that resulted in a patient’s death.

Dr. John Ingle, CIR Regional Vice President and a fourth-year ear, nose and throat resident at the University of New Mexico, added a residents’ perspective. “Considerable scientific evidence backs up what common sense tells me: that life and death decisions should not be made by someone who is sleep-deprived,” said Dr. Ingle. “My patients are consistently horrified when they learn that I haven’t gone to sleep since they saw me the previous day.”

Helen Haskell, the founder and president of Mothers Against Medical Error, became involved in patients’ rights after her 15-year-old son died from a preventable medical error. When her son went to the hospital for an elective procedure in 2000, he died from “failure to rescue,” or failure to recognize and act upon the signs of serious decline in a patient.

“I know that fatigue must have played a role in my son Lewis’s intern’s judgment and in her inability to buck the system for the sake of a patient,” said Haskell. “There is no way I can ever know how large a role it played, but I do know that in those hours of crisis, the last thing we needed was to have an exhausted, unsupervised young trainee as my dying child’s only lifeline.”

The ACGME Board met the weekend of February 6, 2010 to review the work of its Duty Hours Taskforce. ACGME officials have said that they expect to announce a final decision on implementation in September 2010.

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