No Doctor Should Work 30 Straight Hours Without Sleep

No Doctor Should Work 30 Straight Hours Without Sleep

The American medical system requires dangerous feats of sleep deprivation. It doesn’t have
to.

https://www.theatlantic.com/health/archive/2016/12/no-doctor-should-work-30-
straight-hours/510395/

JAMES HAMBLIN
DEC 15, 2016

When Larry Schlachter was a 31-year-old neurosurgeon, he was

driving to the hospital early one morning and “just blacked out.” He
crashed his car and crushed his chest; broken ribs punctured his
thorax, which filled with air and blood. “I almost died.”
Instead he was left with 14 fractured bones and a lingering loss of
balance. He attributes the blackout to working 120-hour weeks that
left him often on the brink of awareness. He put it to me clinically: “I
was a victim of physician fatigue and exhaustion.”

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Getting five or six hours of sleep—substantial by many physicians’ self-

standards—can leave drivers impaired to a degree that’s similar to
drunkenness. That’s according to findings of a study released this
month from the AAA Foundation for Traffic Safety: Drivers who sleep
only five or six hours in a 24-hour period are twice as likely to crash as
those who got seven or more.

The finding led AAA’s director of Traffic Safety Advocacy and

Research Jake Nelson to recommend on NPR:“If you have not slept
seven or more hours in a given 24-hour period, you really shouldn't be
behind the wheel of a car.”

So, should you be performing neurosurgery?

When the young Schlachter did come back to work, his damaged
vestibular system proved less than optimal. “I lost my balance and just
fell on top of one or two patients in the operating room,” he recalls.

Even if a surgeon doesn’t physically collapse on top of a person,

drowsy doctors are more likely to experience lapses in memory and
judgment that can prove critical. In other words, the brains of doctors
are subject to the limits of physiology in much the same way as other
human brains.

In this month’s issue of The Atlantic, I wrote about my

experience with sleep deprivation during medical training, and since
publication, I keep hearing iterations of the same response—a version
of what this caller asked on a Wisconsin Public Radio show on which I
was a guest yesterday: “I remember 30 years ago in a human
physiology class, it seemed like there was a good understanding then
of sleep cycles and how harmful it can be to mess them up. I wonder
why the medical profession—the one that should understand this the
best—seems to be the one that kind of abuses this the most?”

It’s an especially timely question, because right now things stand to

get only more extreme for medical residents. The organization that
makes the rules for medical trainees—the Accreditation Council for
Graduate Medical Education (ACGME)—is proposing increasing the

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current number of consecutive hours that young doctors can work,

from 16 hours to 28 hours.

When I was a medical intern (the first year after graduating medical
school) in 2009, the limit for people in my position was 30
continuous, sleepless, busy hours. The Institute of Medicine had
issued a report the year prior saying that was unsafe. At the request of
Congress, the physician body had audited the ACGME rules and said
that the limit for shifts should be 16 hours. (Or 30 hours with a “5-
hour protected sleep period” in the middle. Which sounds meager, but
there were times I would have sold my soul for even 20 minutes of
sleep.)

In 2010, the ACGME changed its rules accordingly—for first-year

residents, at least. Hearing that, I thought I’d be the last class to have
his first-ever hospital shift be 30 hours in the ICU. That mix of panic,
inadequacy, and exhaustion that I wish on no person—for the new
class, that would simply be a mix of panic and inadequacy. The
exhaustion from 16-hour days would be more chronic than acute.

But now the ACGME is proposing raising that limit back up to 28

hours. The group is currently accepting public comments on proposed
revision, until December 19. After that, the task force will use the
comments to inform final recommendations.

I asked the ACGME why this is happening. The group’s spokesperson

said no one was available to talk to me for a few days, but they were
happy to answer my questions in written form, which they did (and
that’s why the quotes here sound stilted).

The group said the 28-hour maximum is “based on new evidence,

research and expert input.” At a national meeting in March of 2016,
the ACGME heard perspectives from specialty societies, certifying
boards, patient-safety organizations, resident unions, and medical
student organizations. Among the new evidence since 2011, the most
influential study was a large survey of surgical outcomes. Published
earlier this year The New England Journal of Medicine, it found that

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for surgical residents, “Less-restrictive duty-hour policies were not

associated with an increased rate of death or serious complications.”

The study began in the fall of 2014, when Northwestern researchers

compared programs that allowed residents to work longer shifts. They
also didn’t have to be given eight hours off between shifts, or 14 hours
off after a 24-hour shift. In these hospitals, rates of death and surgical
complication were comparable. So the authors concluded that “flexible
duty-hour policies for surgical residents were non-inferior to current
ACGME duty-hour policies with respect to patient outcomes.”

Of course, non-inferior does not mean superior. The study did not
compare the actual hours worked by residents, only the guiding
policies; and it didn’t assess the effects of exhausted residents on
nurses and other clinical colleagues, who may have served as
safeguards against error. The trial also didn’t test the 16-hour versus
28-hour maximum. Another trial is doing that currently—
called iCOMPARE, it is a large collaboration between the University of
Pennsylvania, Johns Hopkins University, and Harvard Medical
School. But those results are not yet known.

Nonetheless, the ACGME has decided to propose repealing the 16-

hour cap for first-year residents. As the group explained it to me, the
cap “may not have had an incremental benefit in patient safety, and
there might be significant negative impacts to the quality of physician
education and professional development.” Letting first-year doctors
work 28 hours “puts first-year residents on the same schedule with
other residents, and is a commitment to team-based care and seamless
continuity of care that promotes professionalism, empathy, and
commitment among new physicians.”

In other words, that’s the culture. Patients and colleagues feel bad, and
you will, too. That may be less absurd than it sounds. Even Schlachter
agrees this cultural component is important. Part of medical education
is teaching dedication. “I should be at the front of the line saying that
residents shouldn’t be pushed to the point where they can't take care
of themselves,” Schlachter told me, “or when their safety is
endangered.”

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He injured his hand several years ago and had to give up

neurosurgery, so he went to law school and now works as a medical
malpractice attorney. In that capacity, he is profoundly critical of
hospital culture. But ultimately he’s on the fence about the work-hour
restrictions: “When I came up, we worked 120 hours a week as
residents. We were committed—it was like Marine boot camp. But that
kind of training follows through into your care of patients. Things have
evolved now to the point where doctors are shift workers. They don't
care as much. They don't feel that responsibility as much.”

Is so many hours in an inpatient setting really what takes to teach

dedication, responsibility, and commitment? Especially when most
American illness is chronic, and the most cost-effective and
underutilized solutions are preventive? Are other professions—where
people sleep at night, every night—failing to instill dedication?

And what about the health and safety of young physicians? The
evidence that sleep deprivation is a serious health hazard is mounting
daily. For just one example, a study in Science that haunts me is one
suggesting a function of sleep is to flush metabolic byproducts and
toxins from the brain—including the beta-amyloid plaques that
accumulate in Alzheimer’s disease. Sleep-deprived people are
at higher risk of diabetes, obesity, depression, and cardiovascular
disease.

I put the question of resident health concerns to the ACGME directly.

They answered less so: “The ACGME is committed to addressing
physician well-being and recognizes that many factors contribute to
well-being, beyond hours worked.” (Though what we’re talking about
is hours worked.) The group went on to detail ways that residents will
have support if they are feeling exhausted or burned out, like
provisions for transitioning the care of patients to other doctors when
a resident is fatigued or ill; and the requirement that hospitals “must
provide adequate sleep facilities and safe transportation options for
residents who may be fatigued.”

It’s delicate language—suggesting that a person may occasionally be

fatigued after running around a hospital for 28 hours. And the

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problem for me was almost never that there wasn’t a bed, but that if I
had chosen to use it, patients would’ve gone neglected. If I said I was
too tired, one of my already beleaguered colleagues would bear that
burden.

Sweeping changes to this complex system are clearly impractical;

inpatient hospital work is a tapestry of personnel dynamics, patients
in need 24-7, multidisciplinary teams to be coordinated and bottom
lines to be met. Doctors today see ever more patients in ever shorter
visits and spend ever more time on paperwork.

In that light, the less discussed factor in work-hour debates is that

residents are a cheap source of labor for hospitals, as compared to
senior doctors. Over the years, representatives from the ACGME and
Association of American Medical Colleges have been emphatic that
hospitals do not profit from the labor of residents. This has been the
long-accepted idea, though it has not born out in independent
analyses or basic economic arguments.

Even though residents are licensed M.D.’s often working 80-hour

weeks—often on the least desirable tasks at the least desirable hours—
resident physicians make $50,000 to $65,000. On a per-hour basis,
that breaks down to less than most ancillary staff at the hospital.
Immediately upon completing the residency program, though, the
same doctors command a salary of four, six, or eight times as much.

Resident labor is made cheaper because salaries are in most cases paid
by the federal government, drawn from Medicare and Medicaid. The
cost to taxpayers is around $5 billion, though profit from residents’
work done goes to the hospital. The money given to hospitals actually
exceed the residents’ salaries by as much as $100,000 per resident.
The rest goes to the hospital, officially to cover administrative costs of
running a residency program—a staff-administrator to oversee the
program, often a daily lunchtime lecture, malpractice insurance, and
some time allotted for senior physicians to see patients alongside the
residents.

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In either case, the workflow in many hospitals would crumble if

residents instantly started working 10-hour days and rarely overnight.
A 16-hour maximum, though, represented incremental movement
toward a change in culture. The medical profession is rife with
stubborn adherence to tradition, but it is an especially dramatic failure
of imagination to think that a well-slept physician workforce is simply
precluded by the nature of the work. It is clearly true that shift changes
are a source of miscommunication and error, but it’s deeply
unimaginative to consider that the solution is to keep people working
beyond the point that neurobiology tells us our systems can function
well, even adequately.

JAMES HAMBLIN , MD, is a senior editor at The Atlantic. He hosts the video series If Our
Bodies Could Talk and is the author of a book by the same title. | More

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