Petition to Reduce Medical Resident Work Hours
September 2, 2010
PART 4: THE SAME RULES TO PROTECT RESIDENT PHYSICIANS AND SUBSPECIALTY RESIDENT PHYSICIANS WILL ALSO PROTECT PATIENTS
More than just harming resident physicians, long work hours have been shown to have negative effects on patients by increasing chances for accidents and errors in the delivery of medical care. A significant body of literature supports the common-sense notion that it is unsafe to subject patients to sleep-deprived and exhausted physicians-in-training.
In a randomized controlled trial, interns were found to make 35.9% more serious medical errors while working a traditional schedule with 24+ hour shifts occurring every third night, as compared with a schedule that limited their shifts of 16 consecutive hours (p < 0.001). In a separate nationwide cohort study of injuries to patients caused by medical management (adverse events), researchers found that interns working five or more 24+ hour shifts in a month reported 7.5 times as many fatigue-related errors that injured a patient, and four times as many fatigue-related errors that led to a patient’s death than did those who did not work 24+ hour shifts. Altogether, one in five interns reported making a fatigue-related error that injured a patient, and one in 20 reported making a fatal error due to fatigue. These data suggest that thousands of patients may die each year in the U.S. due to resident physicians’ extreme work schedules.
Other studies have shown that well-rested resident physicians outperform their sleep-deprived peers on a wide range of tasks, including basic rote memory, language, and numeric skills; retention of information and problem-solving skills; tests of visual attention, short-term memory, and coding ability; and tests of concentration. The procedural skills of resident physicians have also been shown to suffer under conditions of sleep deprivation or restriction, with decreases in resident physicians’ performance of electrocardiogram interpretation, anesthesia monitoring, intubation of mannequins, and simulated laparascopic cholecystectomy. A paper published in the journal Nature found that staying awake for 24 hours impairs cognitive psychomotor performance to the same degree as having a 0.1% blood alcohol level, a value above many U.S. legal driving limits (0.04 g. %-0.08 g. %).
One of the strongest arguments for reducing resident physician work hours is an ethical one: overwork interferes with the development of professional values and attitudes that are an essential part of being a physician. Fatigue can cultivate anger, resentment, and bitterness — often directed at the patient — rather than kindness, compassion, or empathy. As was evident from many of the studies on negative mood and its relationship to long work hours, this attitude is promoted when meeting a patient’s needs becomes incompatible with meeting a resident physician’s own needs. The following entry from a resident physician’s diary illustrates the types of feelings engendered by typical resident physician work schedules:
1AM and I’m ready to go to bed: one should never be ready to go to bed in the ICU [Intensive Care Unit] — you’ll always be disappointed. Anyway, I’m on my way to the EW [Emergency Ward] … when there’s a code [cardiac arrest]. Get up there and find [a resident physician] trying to intubate a lifetime asthmatic who is as blue as this ink. I keep thinking — he’s blue enough to go to the ICU. I keep hoping he’s going to be too blue to go anywhere. Probably a nice man with a loving wife and concerned children, but I don’t want that SOB to make it because I’ve got one special who is going to keep me up 2 more hours. I don’t need an intubated, blue, pneumothoraxed SOB coming to my unit… I don’t want the asthmatic SOB to live if it means I don’t sleep. I don’t want the special to live if it means I don’t sleep. I just want sleep.
Although patient protection is not the principal focus of this petition, it is clear that in protecting resident physicians from long work hours, OSHA would also be protecting patients.
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