Fatigue May Pose Threats to Medical Residents
New research sheds more light on the debate over intern work hours.
As the days grow colder and the holiday season unfolds, thoughts often turn to time spent with family and friends and the struggle to achieve a healthy balance between our professional and personal lives. For physicians and nurses who must offer excellent care 24 hours a day, 365 days a year, the question of how to establish an appropriate equilibrium between time off and time spent training and tending to patients has often been the subject of controversy. At the center of the debate has been the ongoing effort to properly regulate medical residents’ duty hours.
“Most people are concerned about whether medical interns are so tired during their long shifts that they will make mistakes,” explains Robert Wood Johnson Foundation (RWJF) Clinical Scholar (2012-2014) Lisa Rosenbaum, MD. In her recent article, “Residents' Duty Hours—Toward an Empirical Narrative,” (New England Journal of Medicine, November 22, 2012), Rosenbaum revisited the 1984 case that forever changed ideas about how medical residents should be trained.
When 18-year-old Libby Zion lost her life to a lethal drug interaction caused by residents’ erroneous diagnosis and subsequent inappropriate treatment, attention immediately turned to the fact that the residents treating her had been on duty for 18 hours straight. Over the next few years, several studies sought to prove the link between overworked medical interns and medical errors, with some success, though Rosenbaum argues that more research is needed.
“There was only one randomized trial suggesting that shorter duty hours for medical residents lead to fewer errors, and that study had many limitations. The bottom line is there is a need for many more trials in many more settings,” says Rosenbaum. She and her co-author, Daniela Lamas, MD, also argue for greater flexibility in the application of current resident duty hour regulations.
Gone are the once mandatory, somewhat brutal 30-hour shifts routinely assigned to medical residents at American hospitals. As of 2011, new laws and intensified oversight were put into place to ensure that residents would be relieved of duty after 16 hours, regardless of hospital staffing or patient needs. While the public seems to have been relieved by this decision, Rosenbaum and other medical experts think it may have been too extreme.
“During my training, I noticed that there’s a tremendous amount of energy invested in getting residents out of the hospital on time. I began to wonder whether there were reliable data on the benefits of the 16-hour shift time frame,” Rosenbaum says.
A Unique Perspective
Rosenbaum comes to medicine with an insider’s view because it’s her family business. “My grandfather was a physician, my mother is a cardiologist, and my father is a rheumatologist,” she says. Recalling a mom who worked 100 hours a week and was an excellent physician and wonderful parent, Rosenbaum adds that “there’s a necessary stamina needed to see patients through an illness, especially in cardiology. You need to be there, to talk with the family and get them through a crisis. If residents are trained by working 16 hour shifts, adjusting to a 90 to 100 hour work week can be a great shock. We have no idea whether those training in this new system will be equipped to meet the real demands of patient care once they are in practice.”
Her own training in cardiology also exposed Rosenbaum to circumstances that led her to doubt the effectiveness of shorter shifts. In one instance, she worked a 30-hour shift in an intensive care unit. It was an anomaly, but necessary at the time. “That experience was wonderful. I was tired, but I loved it. I felt so much a part of things and it remains difficult for me to understand how one can develop a sense of an unfolding illness without experiencing it firsthand,” she says.
Seeing Both Sides: Seeking a Middle Path
Yet, Rosenbaum says she also understands the other side of the debate. “Ours is a generation that makes life balance a priority. It’s a whole new world. I enjoy many activities outside of the hospital that I likely would have missed had I trained 30 years ago. But will I have the same sense of what it really means to be a doctor?”
“My parents were on duty every third night and there were fewer women of childbearing age in the profession. I don’t think anyone wants to completely go back to that. It’s completely normal now for women to have children during training,” Rosenbaum says.
She acknowledges other models of training, such as the European system in which interns work even fewer than 16 hours at a time, as well as the different demands of various medical specialties. But she recommends that the Accreditation Council for Graduate Medical Education, the group that establishes national standards, allow sufficient flexibility in the duty hour system so that robust trials can be conducted to assess the policy’s impact.
In time, Rosenbaum says, we could have answers. “In 15 years, we will have a much better idea of what this transformation of our education actually means, both for patients and doctors, but only if we have the opportunity to gather the proper data today.”