A frightening study, recently reported in the New England Journal of Medicine, found that long-haul truck drivers frequently nod off on the road. An accompanying NEJM editorial forcefully emphasized the safety importance of adequate sleep. Yet, somehow medicine's premier journal ignored physician training, in which residents work even longer hours without any sleep at all. If driving a truck on five hours of sleep is dangerous, surely taking care of deathly ill patients on no sleep is too.
The trucking study found that, although long-haul drivers had at least eight hours off a day, they slept only 4.8 hours on average--night-haulers just 3.8 hours. It clearly wasn't enough. Surveillance videotape showed that 56 percent drifted off for at least six minutes while traveling over 45 miles per hour. Drowsiness was worst during the night and among those with the least amount of sleep. On brain-wave recordings, two drivers even fell into light sleep--one for 8 minutes, 40 seconds. Fortunately, no one crashed. Nonetheless, sleepy truckers were dangerously impaired.
The NEJM editorial hailed the study as yet more evidence that sleep deprivation kills. Penned by Stanford sleep expert Dr. William Dement, the editorial pointed to previous work showing sleep loss harmed performance just as much as alcohol did. Truckers and pilots who work drowsy, it said, are as dangerous as those who work drunk. And residents? According to Dement, his original version did include residents, but NEJM editors removed such references. Perhaps it was because of length, he suggested. A more likely explanation is that the journal found it easier to needle others than to take on its own profession. The NEJM declined to comment.
In residency, sleep deprivation, like illness and death, is a fact of life. Fresh out of medical school, residents get on-the-job training performing day-to-day patient care in academic hospitals. According to these hospitals, first-year residents work 70- to 80-hour weeks and up to 30 days consecutively (and some think these estimates understate the case). Residents routinely work 36-hour stretches, often without sleep.
D uring my first two years of surgery residency, I worked from 80 to 110 hours a week, depending on how busy things were. Typically, I arrived at 5 a.m. and left at 7:30 p.m., except every third night when I stayed to take care of patients while my team went home. Pages were incessant: "Mrs. T just threw up," "The gallbladder lady isn't breathing very well." I got sleep in snatches--some nights totaling four hours or more, others none at all. Regardless, I operated through the next day like any other.
Constant fatigue can't be good for patient care. In the infamous Libby Zion case in New York City, in which an 18-year-old died while under a fatigued resident's care, a 1984 grand jury denounced physician training as unsafe. Yet, over a decade later, no rigorous research like the trucking study has been done. The limited studies that exist bode poorly for good doctoring. Although tired residents maintain reaction time and manual dexterity surprisingly well, they exhibit memory deficits, difficulties thinking clearly, and decreased vigilance. They also develop alarming levels of hostility toward patients.
These studies ring true to me. To be sure, I'm often amazed at how well I can do on no sleep. When you're faced with a dying patient or a difficult operation, adrenalin focuses your mind and marshals your energy. I honestly think I'm dependable in clutch situations, even after 36 hours on the job.
But I'm also sure that routine care suffers. Good care for sick people depends on attention to details--getting drug doses right, checking every lab result and X-ray conscientiously, remembering a patient's allergies and old medical problems. No matter how hard I try, I know my memory and vigilance fail when I'm sleep-deprived. At times I was so tired that I gave nurses orders that I later couldn't remember giving. Backup systems do catch mistakes. The computer won't accept my drug orders if I prescribe the wrong dose or ignore an allergy. Nurses remind me to check an X-ray or question me when my order doesn't seem right. Nonetheless, many errors are not caught, and I know I have seriously harmed patients because of fatigue.
I've felt the hostility, too. When you're finally set to sleep or go home, nothing is more frustrating than a patient having unexpected problems. Rest becomes a matter of personal survival, and residents can be chillingly brusque with patients who need only time and sympathy. Anger is so common that one Harvard residency program gives an "award" each year to its angriest interns.
Can anything be done? Hospitals could hire more residents, but that would increase our physician glut. In fact, Congress banned hospitals from increasing resident hires this year. Hospitals could hire physician assistants to handle calls that don't require doctors, but that's expensive. Physician assistants get paid twice a resident's $30,000 yearly salary for working only 40 hours a week. In New York state, guidelines for an 80-hour maximum workweek were estimated to increase staffing costs by a quarter-billion dollars per year. Exceptions were quickly carved out (for example, surgical residents aren't included), and even then many hospitals could not afford to stick to the guidelines.
Increasingly, hospitals use "cross coverage," in which a fresh resident covers patients for several other residents at night. However, a Harvard study showed that the covering residents made serious mistakes six times more often than even fatigued residents. They had too many patients and, with every patient new to them, didn't know important details. Tired doctors may not provide the best care, but neither does a series of faceless doctors working shifts.
Research by sleep experts, to examine resident safety and to test solutions, is needed. In any other circumstance, doctors would champion thorough, dispassionate investigation and spare no expense to improve patients' lives. But on this subject, the medical profession is asleep at the switch. If it doesn't wake up soon, another scandalous case will inevitably surface, and the government will take matters into its own hands.