Operating over the limit
NO ONE CAN operate safely on patients after three days without sleep. Yet, for decades, surgical residents routinely worked 120 hours per week and for more than 80 consecutive hours at least one weekend per month (from 6 a.m. Friday through Monday afternoon). Then, six years ago, facing the threat of federal legislation to limit resident work hours, the profession’s accrediting council set the maximum shift length at 30 consecutive hours, though still allowing resident physicians to work 120 hours in any given week and for up to 26 consecutive days, so long as they average 80-88 hours per week and receive four days off each month.
It was disappointing to learn this week that, despite repeated assurances of compliance, the surgical training program at the Massachusetts General Hospital was put on probation for continuing to violate the 2003 work-hour limits. The surgeons who honestly reported the hours the hospital required them to work are courageous to have put patient safety ahead of job security. They well know that Johns Hopkins banished a resident physician who did the same thing; fortunately, Ohio State allowed him to finish training there. Their courage in the face of strident faculty opposition to work-hour reform is a refreshing respite from the systematic falsification of resident physician work hours that has occurred nationally since the limits were implemented. Yet, the unfortunate fact is that the grueling work-hour limits currently in place are woefully inadequate.
Last December, the Institute of Medicine concluded that working for more than 16 consecutive hours without sleep is unsafe for both physicians-in-training and their patients. Why? Because sleep loss impairs brain function, concentration, and coordination, and increases the risk of error. After 24 hours without sleep, attentional failures double, impairment of reaction time is comparable to being legally drunk, and physicians’ clinical performance drops to the 7th percentile of their performance when rested. Not great test scores.
As with alcohol, those affected by sleep loss often do not recognize their impairment. Resident physicians working 30-hour shifts make 36 percent more serious medical errors caring for ICU patients, including 464 percent more diagnostic mistakes, than those scheduled to work 16 hours. They then have a 168 percent increased risk of a motor vehicle crash driving home from these marathon (24-hour) shifts and are 73 percent more likely to stab themselves with a needle or scalpel when performing a procedure after working 20 hours than during a 12-hour shift.
The Institute of Medicine concluded that exhausted resident physicians who have worked more than 16 consecutive hours without sleep should not even be allowed to endanger themselves and others by driving automobiles home, let alone operate on patients. Patients operated upon during the daytime by experienced surgeons have a 171 percent greater risk of a surgical complication, such as organ damage or uncontrolled bleeding, if the surgeon had less than a 6-hour opportunity for sleep the prior night.
It is no wonder that after a year of working 24-hour shifts, one out of five first-year resident physicians admitted making a fatigue-related mistake that injured a patient, and one out of 20 physicians admitted making a fatigue-related mistake that resulted in the death of a patient. Whenever they worked more than five 24-hour shifts per month, the risks of such fatigue-related injuries and deaths increased by 700 percent and 300 percent, respectively.
Yet most Massachusetts teaching hospitals continue the tradition of scheduling physicians to work eight 30-hour shifts per month, despite hazards to patient safety and mounting evidence that sleep plays an essential role in learning. Rather than taking the lead on implementing the safer work-hour limits recommended in 2008 by the Institute of Medicine, as has already occurred at a number of institutions in other states, many academic medical centers in Massachusetts have begun to circle the wagons to block implementation of meaningful work-hour reform.
This is why state Senator Richard Moore introduced bills to limit scheduled resident work hours to 16, and to require hospitals to provide return transportation for fatigued health care providers. I testified in support of both earlier this month. In the meantime, since 24 hours of wakefulness degrades performance comparably to alcohol intoxication, physicians should respect the right of patients to be informed of the impairment and to withhold consent to the risk of receiving care from sleep-deprived providers. Patients have a right to know so they can refuse care from an exhausted physician or surgeon.
Charles A. Czeisler, MD, a professor and director of sleep medicine divisions at Harvard Medical School and Brigham and Women’s Hospital, was a member of the Massachusetts Drowsy Driving Commission and is a member of the Sleep Disorders Research Advisory Board of the National Center on Sleep Disorders Research within the National Heart, Lung and Blood Institute.